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ENCYCLOPEDIA MEDICA

Printed by R. & R. Clark, Limited, Edinburgh.

FOR

WILLIAM GREEN & SONS.
November 1900.

Agents in London. J. & A. Churchill.

,, United States. Longmans, Green & Co., New York.

,, Canada. Carveth & Co., Toronto.

,, South Africa. J. C. Juta & Co., Cape Town.

ENCYCLOPEDIA
MEDICA

UNDER THE GENERAL EDITORSHIP OF

CHALMERS WATSON, M.B., M.R.C.P.E.

VOLUME VI

JOINTS to LIFER

EDINBUEGH

WILLIAM GREEN & SONS
1900

ItrU&l

THE AUTHORS OF THE PRINCIPAL ARTICLES IN
THIS VOLUME ARE AS FOLLOWS :—

Joints, Surgical Pathology of. — Alexis Thomson, F.R.C.S.E., Assistant Surgeon,
Royal Infirmary, Edinburgh.

Kidney —

Physiology of. — T. H. Milroy, M.D., Lecturer on Physiological Chemistry, Edin-
burgh University.

Surgical Affections of. — E. Hurry Fenwick, F.R.C.S., Surgeon, The London
Hospital, London.

Knee-Joint —

Diseases of. — Alexis Thomson, F.R.C.S.E., Assistant Surgeon, Eoyal Infirmary,
Edinburgh.

Injuries of. — A. E. Barker, F.R.C.S., Professor of Surgery, University College
Hospital ; and E. G. Leopold Goffj£, F.E.C.S., London.

Labour —

A. Physiology of. — F. W. N. Haultain, M.D., F.R.C.P.E., Assistant Physician,

Royal Maternity Hospital, Edinburgh.

Duration and Progress. — H. Jellett, M.D., F.R.C.P.I., late Assistant Master
Rotunda Hospital, Dublin.

Diagnosis and Mechanism. — W. R. Dakin, M.D., F.R.C.P., Obstetric Physician,
St. George's Hospital, London.

Management of — Mrs. Chalmers Watson, M.D., late Obstetric Physician to
Plaistow Maternity Institute, London.

Labour in Multiple Pregnancy. — W. Stephenson, M.D., Professor of Midwifery,
University of Aberdeen.

B. Precipitate and Prolonged Labour. — G. E. Herman, M.D., F.R.C.P., Obstetric

Physician, King's College Hospital, London.

Faults in the Passenger. — W. E. Fothergill, M.D., B.Sc, Manchester.

Accidental Complications. — W. W. H. Tate, M.D., M.R.C.P., Assistant Obstetric
Physician, St. Thomas's Hospital, London.

Retained Placenta, etc. — T. W. Eden, M.D., M.R.C.P., Assistant Obstetric
Physician, Charing Cross Hospital, London.

Post-Partum Haemorrhage. — H. Jellett, M.D., F.R.C.P.I., late Assistant Master
Rotunda Hospital, Dublin.

vi LIST OF AUTHOKS

Labour (continued) —

Injuries during Labour. — Amand Eouth, M.D., F.R.C.P., Obstetric Physician,
Charing Cross Hospital, London.

Lacrimal Apparatus. — W. Hill Griffiths, F.R.C.S., Ophthalmic Surgeon, Royal
Infirmary, Manchester.

Lardaceous Disease. — Montagu Murray, M.D., F.R.C.P., Assistant Physician and
Lecturer on Pathology, Charing Cross Hospital ; and W. C. Bosanquet, M.D.,
M.R.C.P., Pathologist, Charing Cross Hospital, London.

Larynx —

Examination of. — W. M. Hunt, M.B., Laryngologist, Royal Infirmary, Liverpool.

Acute and, Chronic Inflammations, etc. — St. Clair Thomson, F.R.C.S., Physician,
Throat Hospital, Golden Square, London.

Chronic Infective Diseases. — P. M'Bride, M.D., F.R.C.P.E., Physician, Ear and
Throat Department, Royal Infirmary, Edinburgh.

Neoplasms, Simple. — W. M. Hunt, M.B., Laryngologist, Royal Infirmary,
Liverpool.

Neoplasms, Malignant. — Sir Felix Semon, M.D., F.R.C.P., London.

Neuroses of. — P. Watson Williams, M.D., Physician, Throat Department, Royal
Infirmary, Bristol.

Affections of Cartilage, etc. — Logan Turner, M.D., F.R.C.S.E., Surgeon, Ear and
Throat Department, Deaconess Hospital, Edinburgh.

Congenital Laryngeal Stridor and Laryngismus Stridulus. — John Thomson, M.D.,
F.R.C.P.E., Physician, Royal Hospital for Sick Children, Edinburgh.

Lens, Crystalline. — G. A. Berry, M.B., F.R.C.S.E., Ophthalmic Surgeon, Royal
Infirmary, Edinburgh.

Leprosy. — G. Thin, M.D., London.

Leucocythozmia. — G Lovell Gulland, M.D., F.RG.P.E., Assistant Physician, Royal
Infirmary, Edinburgh.

Leucocytosis. — R, Muir, M.D., F.R.C.P.E., Professor of Pathology, University of
Glasgow.

Lichen. — W. Allan Jamieson, M.D., F.R.C.P.E., Physician, Skin Department, Royal
Infirmary, Edinburgh.

Life Insurance. — W. Elder, M.D., F.R.C.P.E., Physician, Leith Hospital, Edinburgh.

Liver — -

Physiology of. — D. Noel Paton, M.D., F.R.C.P.E., Lecturer on Physiology, Royal
College of Surgeons, Edinburgh.

Diseases of (other than " Tropical " disorders). — H. D. Rolleston, M.D., F.R.C.P.,
Physician and Lecturer on Pathology, St. George's Hospital, London.

ENCYCLOPEDIA
MEDICA

Joints, Diseases of.

Definition op Tebms applied to
Morbid Conditions of Joints —

Synovitis .... 1

Hydrops .... 1

Arthritis .... 2

Empyema .... 2

Ulceration of Cartilage . 2

Articular Caries . . 2

Disorganisation ... 2

Rigidity .... 2

Contracture ... 2

Ankylosis .... 3
Classification of Diseases of
Joints —

I. Errors of Development 4
II. Bacterial Diseases —

Pyogenic ... 5
Tuberculous . . .10
Syphilitic . . .23
Acute Rheumatism, q.v.

III. Diseases associated with

certain Constitutional
Conditions —

Gout

Chronic Articular Rheu-
matism

Arthritis Deformans .

ffa?mophylia

IV. Diseases associated with

Nerve Lesions —
Neuro- Arthropathies .

V. Hysterical or Mimetic
Joint Affections

VI. Tumours and Cysts

VII. Loose Bodies in Joints .

VIII. Diseases of Special
Joints, q.v.

30
31
32

Definition of Teems applied to Morbid Conditions of Joints. —
Synovitis, while implying inflammation of the synovial membrane,
presents different features according to its etiology. It presents many
analogies with peritonitis. The effusion into the joint, which is a
frequent accompaniment of synovial inflammation, may be serous, sero-
fibrinous, or purulent. It is much to be desired that one should avoid the
use of the term synovitis without some qualifying adjective, which will
indicate its pathological nature, e.g. rheumatic, gouty, gonorrheal, pyogenic,
or tuberculous.

Hydrops, hydrarthrosis, or chronic serous synovitis, are terms employed
when the effusion of fluid into the joint is the most prominent clinical
feature. It presents analogies with ascites or hydrocele of the tunica
vaginalis, and is to be regarded rather as a symptom than as a separate
entity. It may occur apart from disease, e.g. in the knee joint, from repeated
and neglected sprains (football knee) ; it is chiefly met with in the chronic
and intermittent forms of synovitis resulting from chronic staphylococcus
osteomyelitis of one of the adjacent bones, from gonorrhoea, tuberculosis,
vol. vi 1

2 JOINTS, DISEASES OF

syphilis, arthritis deformans, arthropathies of nerve origin, and when there
are loose bodies in the joint.

Arthritis is the term applied, when not only the synovial membrane,
but all the joint structures are involved in the disease, viz. the ligaments,
articular surfaces, and it may be also the ends of the bones. While it may
be anatomically possible to differentiate between synovitis and arthritis, it
is often impossible to do so clinically, so that in practice the two terms are
often used indiscriminately. One may confidently speak of the existence
of arthritis whenever there are marked symptoms of involvenient of the
articular surfaces.

There are as many different pathological forms of arthritis as of synovitis,
so that it is desirable in using the term to add a qualifying adjective which
will indicate its nature, e.g. rheumatic, gouty, pyogenic, or tuberculous.
The arthritis, according to its etiology, may assume a dry form, or it
may be attended with effusion into the joint ; this may be serous, as in
arthritis deformans, or may be sero- fibrinous or purulent, as in certain
forms of pyogenic and tuberculous arthritis. Wasting of the muscles in
the vicinity of the joint is a constant accompaniment of arthritis; it
especially affects the extensor muscles, and is quantitative rather than
degenerative ; the muscles affected do not show the reaction of degeneration.
From the involvement of the articular surfaces it is unusual to have com-
plete recovery from arthritis; it is apt to result in one or other form of
ankylosis.

Empyema is the term occasionally employed to indicate that the cavity
of the joint is full of jpus ; it is chiefly observed in chronic suppurative
disease of pyogenic or tuberculous origin, and is usually attended with the
formation of abscesses outside the joint.

" Ulceration of cartilage " and " caries of the articular surfaces " are
common accompaniments of the more serious and progressive forms of joint
disease, and especially those of bacterial origin. They represent successive
stages in the same destructive process, the disappearance of the cartilage
being frequently followed by exposure and disintegration of the subjacent
bone. The changes which precede and follow upon the ulceration of the
cartilage vary with the joint disease of which it is an accompaniment;
their consideration is beyond the scope of the present article. The occur-
rence of ulceration of cartilage and of articular caries is always attended
with characteristic clinical features, viz., the joint is held rigid by the in-
voluntary contraction of muscles, the wasting of muscles is more pronounced,
and there are " starting pains " at night. Advanced articular caries is
usually associated with some deformed attitude, with shortening, and some-
times with dislocation. It may be possible under anaesthesia to make the
exposed and crumbling bony surfaces grate upon one another. Should
recovery take place repair will usually be attended with fusion of the
opposing articular surfaces by fibrous tissue or by bone.

Disorganisation of a joint is a convenient description of the condition
in which all the constituent parts are damaged or destroyed. It results
from the more severe and destructive forms of joint disease, and especially
those of pyogenic or tuberculous origin.

Conditions of Impaired Mobility of Joints. — (1) Rigidity implies
the fixation of a joint by the involuntary contraction of muscles ; it is some-
times called false ankylosis, because it entirely disappears under anaesthesia.
(2) Contracture is the term applied when the fixation of the joint is due to
permanent pathological changes in the soft parts surrounding it, chiefly
consisting in the shortening of muscles, tendons, tendon sheaths, liga-

JOINTS, DISEASES OF 3

ments, fasciye, and skin ; the parts on the flexor aspect are more liable
to shortening, hence contracture is nearly always associated with flexion.
Contracture results from a number of conditions, apart from disease of the
joint concerned, e.g. disease in one or other of the adjacent bones, lesions of
the motor nervous mechanism, hysteria, etc. (3) Ankylosis is the term
applied to the stiffness or immobility of a joint when it results from
changes involving the articular and other surfaces which normally move or
glide upon one another. It is frequently combined with contracture and
with thickening and induration of the capsular and other ligaments. Three
anatomical varieties of ankylosis are distinguished: (a) the fibrous, in which
there are fibrous adhesions between the opposing surfaces ; these adhesions
may be loose or tight, may be localised in the form of bands, or diffuse
altogether obliterating the cavity of the joint; the stiffness may vary,
therefore, from restriction of the normal range of movement up to close
fibrous union of the bones which may prevent any movement whatsoever.
Fibrous ankylosis may result from injury, especially dislocations and frac-
tures implicating a joint, or from disease, e.g. pyogenic, gonorrhoea! tuber-
culous, rheumatic, gouty, or other form of arthritis, (b) Cartilaginous
ankylosis implies the fusion of two opposed cartilaginous surfaces ; it is best
seen between the patella and trochlear surface of the femur, and between
the femoral condyles and articular facets of the tibia in certain forms of
tuberculous disease of the knee. Clinically it is associated with abso-
lute rigidity of the joint, (c) Bony ankylosis (synostosis) implies an
osseous union between articulating surfaces ; it may be a sequel of
the preceding forms, or it may result from a more direct fusion of two
opposing surfaces subsequent to their having been bared of their carti-
lage. In the majority of cases it is to be regarded as a reparative process,
and as presenting analogies with the union of fractures. It may be a
sequel of almost any one of the diseases known to affect joints. Its
occurrence is not necessarily dependent upon antecedent suppuration in the
joint as was formerly believed. It has been observed to follow the pyogenic,
gonorrhceal, tuberculous, syphilitic, gouty, and neuropathic affections of
joints. It is doubtful if it occurs in the spinal arthropathies apart from
superadded infection ; in arthritis deformans it is also questionable if the
articular surfaces ever become united by bone, although it is common to
have complete fixation of the vertebral and other joints by the ossification
of ligaments and other extra -articular structures (external or peripheral
ankylosis). "While in most cases the occurrence of true bony ankylosis is
readily explained by changes resulting from antecedent disease, the pathology
of certain rarer forms is quite unknown. Ankylosis may certainly occur
apart from any recognised reparative process, and may coexist with other
trophic changes in the skeleton of unknown origin. The name arthritis
ossificans has been applied by Griffiths to a certain group of these exceptional
cases. The origin of ankylosis from simple disuse of a joint has not been
corroborated.

It is important to bear in mind that in any example of bony ankylosis
there are associated changes in the soft parts which, if the limb be fixed
in a vicious attitude, will render futile any operative interference solely
directed to the bones concerned.

Ankylosis of a joint, before the skeleton has attained maturity, has very
little influence on the growth in length of the bones affected ; any arrest
of growth is more likely to depend on changes in the epiphysial junctions
resulting from the original disease.

In the diagnosis between false and true ankylosis it may be necessary

4 JOINTS, DISEASES OE

to anaesthetise the patient. The nature and extent of true ankylosis may
be learned from manipulations of the limb or by skiagraphy. In fibrous
ankylosis mobility may be elicited, although only to a very slight degree ;
in osseous ankylosis the joint is rigidly and immovably fixed ; in the fibrous
variety any attempt to forcibly move the joint causes severe pain, while in
the osseous variety such attempts are painless.

The treatment is influenced by the nature of the original disease, the
variety and attitude of the ankylosis, and the normal functions of the joint
concerned. If the aim be a movable joint in a case of fibrous ankylosis,
treatment is directed towards elongating or rupturing the fibrous union
between the bones. The gradual stretching of adhesions, by exercises,
manipulations, douching, extension, and special forms of apparatus, has
much to recommend it, given the required perseverance and fortitude on
the part of the patient, and the encouragement afforded by indications of
yielding on the part of the adhesions. The forcible rupture of adhesions
under an anaesthetic (nitrous oxide) may be necessary, especially when there
are one or more strong fibrous adhesions or bands ; these give way with an
audible crack : the procedure must be carried out with caution in view of
such risks as fracture of the bone (which is often rarefied), separation of
epiphysis, fat embolism, and restarting of the original disease ; in any case
it is followed by considerable pain and effusion into the joint, which necessi-
tate rest for some days before exercises, massage, and other manipulations
are resumed.

In selected cases of fibrous ankylosis, with or without contracture, it
may be advisable to attempt to secure a movable joint by open arthrotomy,
dividing or removing adhesions, and other contracted tissues ; this procedure,
which has been specially named arthrolysis, has been chiefly practised in
the elbow, and has yielded results which are distinctly encouraging.

If the ankylosis is osseous and a movable joint is desired, e.g. at the
elbow, a sufficient amount of bone, and it may be also of periosteum, must
be resected to allow of the formation of a false joint.

On the other hand, if it he desired that the joint disease should result
in rigid ankylosis, e.g. in certain cases of tuberculous disease of the knee,
treatment may be directed towards favouring its occurrence, and in such an
attitude as will secure the maximum usefulness of the limb concerned. To
this end prolonged immobility in plaster of Paris or other apparatus is em-
ployed. This will not suffice in other forms of joint disease, e.g. arthritis
deformans, spinal arthropathies; in these the articular surfaces must be
removed with the saw in order to bring about osseous ankylosis.

When bony ankylosis has occurred in an undesirable attitude, e.g. flexion
at the hip or knee, it can only be remedied by an osteotomy or wedge resection
of the bone, with or without such additional division of the contracted soft
parts as will permit of the limb being placed in the attitude desired. The
fixation of the bones to each other by means of pegs may hasten the
occurrence of osseous union, and afford an additional security of the correct
attitude being maintained after operation.

I. Errors of Development. — These include congenital dislocations and
other deformities of intra-uterine origin, e.g. abnormal laxity of joints, absence,
displacement, and defective growth of one or other of the essential constituents
of a joint, etc. They are chiefly described under " Deformities," vol. ii.

II. Bacterial Diseases. — In those which arise apart from wounds the
bacteria concerned are carried directly to the joint in the blood stream, or
they are lodged in the first instance in one of the structures (one of the
bones) adjacent to the joint. In the former, i.e. the direct infections, the

JOINTS, DISEASES OF 5

tendency is for all the structures of the joint to be involved simultaneously
and diffusely, whereas in the indirect infections the disease is often localised
to the area first infected, and only becomes generalised at a later
period.

Bacterial affections resulting from infection of a wound implicating the
joint are described under Injuries of Joints.

Pyogenic Diseases. — 1. Those due to common pus organisms (staphylococci
and streptococci).

2. Those related to acute articular rheumatism, pneumonia, typhoid,
small-pox, scarlet fever, measles, diphtheria, erysipelas, dysentery, etc.

3. Those associated with gonorrheal urethritis and gonorrheal oph-
thalmia.

The commoner pyogenic diseases are the result of infection of one or
other of the joint structures with staphylococci or streptococci, which may
be demonstrated in the exudation into the joint, and especially in the sub-
stance of the synovial membrane. The method of infection is the same as
has already been described in diseases of bone (see vol. i.). The organisms
concerned having effected an entrance into the body are carried to
the joints by the arteries. Their localisation in particular joints is de-
termined by injury, exposure to cold, antecedent disease of the joint, and
other factors whose nature is not always apparent. A distinction may be
made between primary infections of joints, in which the organisms involve
articular structures from the outset, and secondary infections in which the
initial lodgment and disease is in one of the bones belonging to the joint
concerned. The former are more often met with in adults, and are illustrated
by the joint suppurations in pysemia and allied conditions. The latter are
more frequent in children, and are illustrated by the well-known " acute
arthritis of infants," in which the joint lesion owes its origin to an osteo-
myelitis in one of the bones adjacent to the joint. The clinical diagnosis
between primary and secondary joint suppurations is rarely possible, because
their features are so very similar, and in the secondary infections it is usual
for the joint disease to so overshadow the bone lesion from which it originates
that the latter element may be only recognised on operating, or on post-
mortem examination.

The clinical features vary with the gravity of the infection. They may
assume the form of an acute serous synovitis which may recover, or become
chronic, or may relapse after apparent cure. The relapsing or intermittent
synovitis or hydrops, which closely resembles that of gonorrheal or tuber-
culous origin, has been shown to depend in certain cases on staphylococcal
disease of one of the adjacent bones, so that treatment of the latter is
essential for permanent recovery.

In a certain number of cases the clinical features of pyogenic infection
are remarkably latent, especially when it occurs in the - course of some
general illness, such as scarlet or other fever. It has been known to escape
notice until the occurrence of some striking development, such as disloca-
tion in the case of the hip joint, or the occurrence at a later period of
ankylosis.

In the graver infections the suppurative element is more prominent ; the
effusion into the joint is purulent ; there is general illness, often ushered in
with a rigor. The local signs and symptoms are those of an acute arthritis,
in which all the joint structures participate, and which, if left to itself, may
result in disorganisation. The synovial membrane is converted into granu-
lation tissue. The ligaments and inter-articular cartilages share a similar
fate. The articular cartilages, which are at first dulled and macerated,

6 JOINTS, DISEASES OF

undergo fibrillation and necrosis, and separate in visible fragments. The
subjacent bone which is thus exposed becomes the seat of inflammation and
granulation, so that it disintegrates, the so-called articular caries. These
changes in the articular surfaces add materially to the gravity of the lesion
and to the suffering of the patient. The joint is held rigid by the in-
voluntary contractions of muscles. The least attempt at movement causes
severe pain. The slightest jar, even the shaking of the bed, may cause
agony. Sleep is impossible, or is disturbed with " starting pains." The
distension of the joint and fluctuation may be evident, or may be obscured
by oedema of the overlying soft parts. Sometimes the entire limb is swollen
and oedematous. In untreated cases the joint is usually allowed to become
flexed. At the knee the angle of flexion may be so acute that the heel
touches the buttock. The pus in the joint may perforate the capsule and
spread in the surrounding tissues up and down the limb. Sooner or later
it ruptures on the surface and discharges externally through one or more
sirmses. The final disorganisation of the joint with destruction of the
ligaments, may be indicated by abnormal mobility, by grating of the
articular surfaces, or by dislocation. In the acute arthritis of infants the
epiphysis may be separated and displaced. The progress of the local disease
is associated with aggravation of the general symptoms, and the patient is
exhausted with suffering and poisoned with toxines.

In the course of pymmia joints may become distended with pus without
any pronounced changes in the joint structures, without local signs except
those indicating the presence of fluid, and without much complaint on the
part of the patient.

"When the joint is the seat of a direct infection through an external
wound, either accidental or operative, the condition is commonly spoken of
as a septic arthritis. Its morbid anatomy and clinical features are similar
to those described when the infection has been carried to the joint by the
blood stream, but the lesion is usually more severe and destructive, and is
more likely to persist and to result in osseous ankylosis.

The terminations vary with the gravity of the infection and with the
stage at which it comes under surgical treatment. In the milder forms
recovery is the rule, with more or less complete restoration of function. In
the more severe forms, and especially when several joints are involved, death
may result at an early stage from general pyogenic infection or toxaemia,
or at a later period with symptoms of hectic fever, waxy degeneration, and
exhaustion. If the patient recovers, the joint or the entire limb may be
permanently damaged. There may be fibrous or bony ankylosis, and this
may be in a good or in a bad position. There may be deformity from dis-
placement or dislocation. Erom changes in the periarticular structures
there may be contraction of the limb in the flexed or other undesirable
position, and in the case of young subjects there may be interference with
the future growth of the limb. The persistence of sinuses is usually
associated with disease in one or other of the bones belonging to the
joint.

The diagnosis, while easy and straightforward in the graver suppurative
forms, may be difficult in the milder varieties, for these may resemble very
closely the serous effusions in syphilis, gonorrhoea, and tuberculosis, or that
caused by injury where there is no question of infection.

The treatment is governed by the same principles as guide us in the
treatment of other pyogenic infections. The limb is immobilised and
elevated. The altitude preferred will be that in which, should stiffness
occur, there will be least interference with function. Extension by means

JOINTS, DISEASES OF 1

of the weight and pulley may relieve symptoms and counteract any tendency
to flexion.

While the application of ice or leeches to the joint is recommended by
some authorities, others prefer an antiseptic compress of 2\ per cent carbolic
lotion or 1 per cent formalin. A more important question is that of evacuat-
ing the fluid in the joint. If the latter is in sufficient quantity to cause
tension, or if it tend to persist, or if from the temperature and other indica-
tions there is reason to suspect that it is purulent, it should be evacuated
without delay. A trocar and. cannula may suffice in the serous variety ; the
suppurative forms demand incision and drainage. In addition, the joint
may be gently washed out with salt solution, with or without a preliminary
washing with an antiseptic (1-2000 corrosive sublimate). It is a common
experience that many forms of acute suppuration in joints (e.g., the acute
arthritis of infants, the suppurations in pyaemia) yield at once to incision
and drainage, if carried out sufficiently early and. before any destructive
changes have taken place.

On the other hand the results of simple drainage may be unsatisfactory.
The temperature and other indications of progressive mischief may call for
further interference. Continuous irrigation, with multiple openings for
drainage, may be given a trial, or the joint must be laid freely open so that
every pocket and recess will be exposed to view. In certain joints this is
only attainable by resecting one or other of the bones belonging to it.

Amputation is to be had recourse to, if life is threatened by general
infection, or if the limb is likely to be useless.

It goes without saying that the occurrence of suppuration in the peri-
articular soft parts, or in one of the adjacent bones, must be looked for and
promptly dealt with.

When convalescence is established attention is directed to the restora-
tion of the functions of the limb, to the prevention of stiffness and deformity
by movements, massage, hot air and other baths (see p. 4).

At a later stage, and especially in neglected cases, operative and other
measures may be required for deformity or stiffness.

For details of treatment see the individual joints.

In typhoid fever joint lesions may result from infection with the typhoid bacillus,
or with ordinary pyogenic organisms. They have been observed, especially in the
hip joint, in the shape of an arthritis, with or without suppuration. They are
sometimes remarkably latent, and may result in spontaneous dislocation (on slight
movement, or on lifting the patient), or in ankylosis. They are very amenable to
treatment.

In acute pneumonia different forms of arthritis occur, due to the pneumococcus.
They are sometimes serous, sometimes of an acute suppurative character. The
prognosis is described as unfavourable, because of the frequent occurrence of
similar lesions in other serous membranes, viz., pleurisy, pericarditis, meningitis.

In small-pox it is not known whether the joint lesions are due to the specific
virus of that disease or to ordinary pyogenic organisms. They may be serous in
character like those of acute rheumatism, and may pass from one joint to another.
The purulent forms are met with in relation to the suppurative stage of the skin
eruption.

In scarlet fever joint lesions are comparatively common. They were formerly
described as scarlatinal rheumatism. Our knowledge of their bacteriological nature
is very imperfect. The most frequent clinical type is that of a serous synovitis,
occurring within a week or ten days from the onset of the fever, more common in
persons over fifteen years and in females. Its favourite seat is in the hand and
wrist, involving the sheaths of the extensor tendons as well as the joints. It does
not tend to migrate to other joints, and it rarely lasts longer than a few days. It
is probably due to the specific virus of scarlatina. Joint lesions more closely
resembling those from ordinary pyogenic infection are much less frequent than
the preceding type. They occur more often in children, at a later stage of the

8 JOINTS, DISEASES OF

fever, and in cases in which the throat lesion is severe. The arthritis may be
acute and suppurative, may affect several joints, and may exhibit a grave septi-
cemic or pysemic character. Authorities also describe a " true rheumatic arthritis "
occurring when convalescence from scarlet fever is well advanced, favourably
influenced by anti-rheumatic remedies, and sometimes complicated with endo-
carditis and with chorea.

In measles joint lesions are much rarer, and are said to be less serious than in
scarlet fever.

In diphtheria they are also very rare. A hydrops of the knee has been recorded
during the second week of the disease in which Loeffler's bacillus was present.
Probably the majority of the joint complications in diphtheria are related to
streptococci, which enter the body by way of the throat lesion.

In erysipelas effusion into joints is very exceptional. It may be purulent.
Streptococci have been found in the fluid. Sometimes the joint is infected when
erysipelas passes over it.

In dysentery the joints are occasionally affected. Two varieties of lesion are
described — a dry form in which there is polyarticular pain affecting different joints
with great rapidity and unaccompanied by effusion ; the second, which is especially
met with in the knee, is attended with an abundant exudation, strongly fibrinous
in character, but in which no organisms, amoebic or otherwise, have been found.
From the tendency of the fluid to persist it is usually necessary to evacuate it
through a cannula.

The joint lesions which accompany acute rheumatism may be provisionally
included with the other members of this group, although their infective nature
has not been established. For a description of them the reader is referred to the
article on acute rheumatism.

Joint affections associated with puerperal fever, otitis media, etc., are not in
any sense specific, for they are the result of infection with the common pyogenic
organisms.

Gonoeehceal Affections of Joints. — These include all forms of joint
lesions associated with gonorrhoeal urethritis or gonorrhoeal ophthalmia.
They may develop at any time during a gonorrhoea, but are usually met
with when the infection has reached the deeper urethra. They have been
observed after the discharge has ceased. There is no connection between the
severity of the gonorrhoea and the liability to joint disease. The gouty
and rheumatic are supposed to be more liable. The sexes are affected with
equal frequency.

As a complication of ophthalmia the joint lesion occurs more commonly
towards the end of the second or during the third week.

The joint lesions may be the only evidence of metastatic infection, or
they may be part of a gonorrhoeal pyaemia, involving the endocardium,
pleura, tendon sheaths, etc. The gonococcus is nearly always' present in pure
culture ; it is found with most certainty in the synovial membrane, in which
it is first deposited from the blood ; it may be impossible to find it in the
exudation in the joint unless at the first onset of the disease. In the
purulent forms of joint lesion the gonococcus may alone be present, or it
may be associated with staphylococci or streptococci, the latter being derived
either from the urethra or from elsewhere (throat, intestines, etc.).

The order of frequency in which the joints are affected is as follows : —
knee, elbow, ankle, hip, foot, wrist, shoulder, fingers.

The joint affection is more often mono-articular than polyarticular.

The following clinical types may be differentiated ; they may, however,
merge into one another.

1. A dry polyarthritis, like chronic rheumatism, sometimes trifling and
evanescent, and it may be recurring with each attack of gonorrhoea, or per-
sistent and progressive, resulting in partial or complete stiffening of the
joints affected, and permanent crippling of the patient.

2. A form of chronic synovitis or hydrops, in which the joint, nearly
always the knee, on one or both sides, quietly fills with fluid of a serous or

JOINTS, DISEASES OF 9

sero- fibrinous character ; it closely resembles the hydrops from other causes ;
it is indolent, may readily subside under rest, and then relapse, or may be
very persistent and disabling. When recovered from, the joint may be
expected to return to its normal condition.

3. A more acute general inflammation of the joint (arthritis) may begin
as such, or follow on a milder form of the disease ; there is sudden onset of
severe pain, swelling, inability to use the limb, and considerable fever ; the
swelling may extend well beyond the limits of the joint, and may be
associated with cedema of the soft parts, the skin may be red and hot as
in erysipelas ; the adjacent tendon sheaths and bursse, especially at the
ankle, wrist, and knee, may be simultaneously involved. While resolution
is possible the tendency towards stiffness and ankylosis is considerable.
The ankylosis, at first fibrous from close adhesions between the surfaces,
may become bony, and may be associated with flexion or other deformity.

This type of gonorrhoeal joint disease maybe mistaken for acute rheuma-
tism. The points in diagnosis are : its sudden onset without apparent cause,
there is less tendency to wander from joint to joint once it has settled down,
it is little influenced by salicylates, and it is frequently, if not always mono-
articular. In the author's experience it is more often met with in the elbow.

4. A suppurative form, or empyema, like that from ordinary pus
microbes ; it is usually single, but may be multiple ; it is fortunately rare,
because it is very serious, endangering the joint, or the limb, or life itself.
It may be the result of gonococcal infection alone, or of a mixed infection.
Abscesses may form outside the joint. Eecovery is attended with
ankylosis.

The diagnosis of gonorrhoeal affections of joints is often missed, because
gonorrhoea is not suspected by the practitioner ; the denial of the patient is
not to be accepted, especially in the case of women ; sometimes the patient
is really ignorant. The points in diagnosis from acute rheumatism have
been already indicated.

The prognosis should always be guarded because the disease may relapse,
or may prove tenacious and persistent ; the patient may be laid up for weeks
or months, and may be finally crippled in one or in several joints.

The treatment (besides that of the urethral disease) consists in complete
rest until all symptoms have disappeared. Salicylates may relieve suffer-
ing, but are not curative.

Iodide of potash may also relieve symptoms. Locally, the joint is
immobilised by means of a splint, or by cotton wool and an elastic bandage ;
extension is employed in the case of the hip.

Great relief may be obtained from very hot baths, to which turpentine
and black soap may be added. Konig recommends the use of tincture of
iodine applied several times a day. In the persistent dry forms the hot-
air bath or Bier's method by venous congestion may be employed. In
hydrops, when the fluid persists, tapping should not be too long delayed ;
the joint may be washed out with a one per cent solution of protargol. The
purulent form is to be treated on general principles.

After all symptoms have settled down, but not till then, for fear of
exciting relapse or metastasis, the joint may be massaged and exercised ;
stiffness from adhesions is most intractable, and may, in spite of every
attention, terminate in ankylosis ; the latter is to be dealt with on general
principles.

JOINTS, DISEASES OF

Tuberculous Diseases of Joints

General Facts ....

Relative Frequency in different

Pathological Anatomy —

Joints ....

Relative Frequency of Synovial

Clinical Features .

and Osseous Disease .

Of Tuberculous Joint Disease in

Joint Lesions from Disease in

general

adjacent Bone

Of certain Clinical Types —

Tuberadous Lesions of Synovial

Hydrops

Membrane

Empyema

Changes inArticular Cartilages

White Swelling

Caries of Articular Surfaces .

Arthritis

Caries Sicca

Pathological Dislocation

The general Health

Contents of Tuberculous Joints

Causes of Death .

Periarticular Abscesses and

Diagnosis ....

Sinuses ....

Prognosis ....

Reactive Changes in Vicinity

Treatment —

of Tuberculous Joints

Conservative .

Terminations or Sequelce

Operative . .

Tuberculous diseases result from bacillary infection of the synovial
membrane, or of the marrow of one or other of the adjacent bones.

The infection occurs under similar conditions to those which have been
already described in diseases of Bone (vide vol. i.).

The tuberculous lesions of joints, although having a common origin in
infection with the tubercle bacillus, differ widely in their anatomical and
clinical features. From the anatomical point of view they may be divided
into those in which the disease originates in the synovial membrane and
those which originate in disease of one or other of the adjacent bones.

The relative frequency of these two types has been variously estimated.
The sources of disagreement are to be found in the difficulty in distinguish-
ing them from one another, and in the fact that only the more serious and
more advanced forms of the disease are subjected to operation ; the milder
forms of primary disease in the synovial membrane so commonly recover
without operation that they do not figure in the records upon which the
estimate of the relative frequency is based. It is probable that the
frequency of primary disease in the bone has been exaggerated ; Krause,
for example, estimates the proportion observed in Volkmann's clinique as 23
per cent of synovial origin to 77 per cent originating in the bones.

The relative frequency varies with the age of the patient and with the
joint affected ; in children, the number of cases originating in the bones is
approximately that given by Krause ; on the other hand, primary disease in
the synovial membrane is relatively more frequent in adults. The
predominance of bone lesions in childhood and youth is to be ascribed to the
conditions associated with the growth of the skeleton, especially at the ends
of the long bones.

As regards the joint affected, the maximum frequency of osseous lesions
is found in the hip (26 synovial to 129 osseous, Krause) ; the proportion is
about equal in the case of the knee (266 synovial to 281 osseous, Konig), and
probably also in the case of the elbow, wrist, shoulder, and ankle.

We may preface the consideration of the morbid anatomy of tuberculous joint
diseases by referring, in the first place, to the non-specific lesions met with in joints
tvhen tuberculous disease is present in the interior of one or other of the adjacent
bones.

JOINTS, DISEASES OF 11

They are comparatively common and are often misunderstood in practice.
They resemble those which result from staphylococcal disease in the adjacent bone,
(g.v.). When a tuberculous focus, especially a large one with caseation and a
sequestrum, is seated near the articular cartilage or the attachment of the capsular
ligament, it gives rise to reactive changes in the adjacent joint, characterised by
exudation and by the prolongation of the synovial membrane over the articular
surfaces. Adhesions may result, which may obliterate the cavity of the joint, or
divide the cavity into different compartments. These phenomena are best
observed in the knee. They are analogous to the changes in the pleura in disease
of the subjacent lung and in the peritoneum in disease of the abdominal viscera.
They are of importance because they interfere with the functions of the joint, and
in the event of rupture at a later period of the osseous focus into the joint, they
may limit the articular infection to a small area, and may altogether prevent
the development of the graver forms of tuberculous joint disease.

The infection of the joint from disease in the adjacent bone may take place at the
periphery from the osseous focus reaching the surface of the bone at the site of the
reflection of the synovial membrane ; the infection begins at this point, and then
spreads to the rest of the membrane ; or it may take place in the central area, by
a flood of tuberculous pus escaping into the joint through a hole in the articular
cartilage, or by the projection of tuberculous tissue into the joint following upon
the gradual erosion of the cartilage.

Tuberculous Lesions of the Synovial Membrane and of the Articidar Surfaces. — The
nature of the changes in the synovial membrane depends upon whether the
disease originated in the synovial membrane or in the bone, and in the latter case,
whether the osseous focus has erupted directly into the cavity of the joint or has
only infected the synovial membrane at the line of its reflection on to the bone,
and whether the joint was normal or not at the moment of infection.

In the majority of cases the first evidence of disease in the joint is diffuse
thickening of the synovial membrane; this thickening is chiefly due to the formation
of granulation tissue or young connective tissue in the substance of the mem-
brane. It may be described as being arranged in two layers ; the outer layer is com-
posed of more fully-formed connective or fibrous tissue, while the inner consists of
embryonic tissue, usually studded or permeated with miliary and other tubercles.
The tubercles are met with in all stages in the same joint, some in course of active
formation, others quiescent, others again in course of retrogression and cicatrisa-
tion. They may be seen shining through the moist shining layer on the free
surface, or the inner layer of the synovial membrane may undergo fibrinous
degeneration followed by caseation and disintegration, so that the free surface is
covered with a thin layer of fibrinous or caseous pus, and a similar material may
. accumulate in the cavity of the joint. Where there is greater resistance on the
part of the tissues there is active formation of young connective tissue circum-
scribing or encapsulating the tubercles, so that they remain embedded in the
substance of the synovial membrane, and are only revealed when it is cut in
sections ; the surface of the membrane then retains its smooth shining character,
and there may be no fluid in the cavity of the joint.

The new formation of tissue in relation to the synovial membrane is rarely
confined to its normal limits ; it tends to infiltrate the ligaments, and to be pro-
jected into the cavity of the joint, filling up its pouches and recesses and growing
over the surface of the articular cartilages like ivy growing over a wall. Wherever
the synovial tissue covers the cartilage it becomes adherent to it and fused with
it, for covered cartilage always undergoes a retrograde metaplasia into ordinary
connective tissue. The morbid process may be arrested at this stage, and may
cure with fibrous adhesions between the opposing articular surfaces, or it may
progress, in which case further changes occur which result in destruction of the
articular cartilages and exposure of the subjacent bone.

The synovial connective tissue covering the cartilage may at first present no
structural evidences of the presence of tubercle, but in time it acquires the char-
acters of a tuberculous infiltration and exhibits aggressive qualities ; it causes
pitting and perforation of the cartilage, it makes its way through the cartilage,
and often spreads widely between the cartilage and the subjacent bone so as to
separate the cartilage in portions of considerable size. These changes are com-
monly spoken of as " ulceration and exfoliation of the articular cartilage." They
usually commence and are most marked at the points of junction of synovial
membrane and cartilage, viz. at the margins of the articular surfaces, and at the
points of attachment of such intra-articular ligaments as the round ligament in
the hip and the crucials in the knee. The cartilage is also destroyed more rapidly

12 JOINTS, DISEASES OF

and extensively when it overlies a caseating, sclerosed, or other focus in the bone ;
the latter being then exposed in the joint contributes to the progress and aggrava-
tion of the disease.

To a certain extent the cartilage may be regarded as a barrier to the spread of
tubercle, protecting the joint where the disease originates in the bone, and pro-
tecting the bone where the disease begins in the synovial membrane.

Carious changes in the subchondral bone usually follow upon the destruction of
the articular cartilage, and are associated with tubercular infiltration of the
marrow in the surface cancelli, and breaking up of the spongy framework of the
bone into minute irregular fragments ; this disintegration of the surface bone is
known as caries.

The mutual pressure of articular surfaces against one another, resulting from
the contraction of muscles and other factors, favours the progress of ulceration of
cartilage and of articular caries ; these are usually more advanced in areas most
exposed to pressure, e.g. on the superior aspect of the head of the femur and on
the posterior and upper segment of the acetabulum.

When the destructive changes in the articular surfaces are very pronounced,
and at the same time there is an absence of caseation and suppuration, the con-
dition has been called caries sicca.

The occurrence of pathological dislocation, while possible in any joint, has been
specially observed at the hip. It implies softening and stretching of the liga-
ments which retain the bones in their normal position and some exciting factor
causing displacement ; this may be the accumulation of fluid in the joint or of
granulations filling up the socket, or the involuntary contraction of muscles or
some movement or twist of the limb. In some cases the occurrence of dislocation
is favoured by destructive changes in the bones, e.g. diminution in the size of the
head of the femur, and enlargement or actual destruction of a portion of the socket
of the acetabulum. The dislocation may be complete or incomplete. It may take
place gradually and insidiously, or suddenly, especially when it results from some
slight form of external violence, or the spasmodic contraction of muscles acting
on the joint.

Rarer Forms of Synovial Tuberculosis. — While the diffuse thickening of the
synovial membrane, above described, is the most common form of synovial tuber-
culosis, there are others worthy of mention. The synovial membrane may present
nodular masses or lumps, resembling the tuberculous tumours met with in the
brain; they project into the cavity of the joint, may be pedunculated, and may
give rise to the symptoms of loose body. In rare instances the fringes of the
synovial membrane may undergo a remarkable development, like that observed
in arthritis deformans, and may deserve the name arborescent lipoma. Both these
types are met with in the knee joint.

The Contents of Tuberculous Joints. — In a large proportion of cases of synovial
tuberculosis the joint cavity is entirely occupied by the diffuse thickening of the
synovial membrane, and there is an absence of fluid in the joint. In a small
number there is an abundant serous exudation, as in a pleurisy, and the condition
is known clinically as hydrop>s. There may be a considerable formation of fibrin
tvithin the joint, covering the free surface of the membrane, and floating in the
fluid as shapeless flakes or masses ; under the influence of joint movements they
may assume the shape of melon seed bodies {corpora oryzoidea). More rarely the
joint contains tuberculous pus, and the surface of the synovial membrane resembles
the wall of a cold abscess {empyema of joints).

Periarticular Tubercle and Periarticular Abscesses. — These may result from the
eruption on the periosteal surface of foci in the interior of the bones, or from the
extension of foci in the synovial membrane into the surrounding cellular tissue
either by direct continuity or by way of the lymphatics. A collection of pus
within the joint may perforate the capsule and infect the tissues outside the joint.
The periarticular abscesses, after spreading in various directions, finally reach the
skin surface and give rise to tortuous sinuses ; the more distant sinuses may be
the result of the spread of tuberculosis along the tendon sheaths in the vicinity of
the joint.

Reactive changes in the vicinity of tuberculous joints are of common occurrence,
and play a considerable part in the production of what is known clinically as
ivhite sivelling. New connective tissue forms amidst the periarticular fat and
between muscles and tendons ; it may be fibrous and tough, or it may be soft,
vascular, and cedematous ; the periarticular fat may become swollen and gelatinous,
constituting a layer of considerable thickness, in which tubercle may be entirely
absent. This is commonly known as gelatinous degeneration. It is supposed that

JOINTS, DISEASES OF 13

the fat disappears and is replaced by a mucoid effusion between the fibrous
bundles of connective tissue, these changes resulting from interference with the
circulation and nutrition of the tissues concerned. In the case of the wrist the
newly-formed connective tissue may fix the tendons in their sheaths, and may
seriously interfere with the movements of the fingers. In relation to the bones
there may be reactive changes, resulting in the formation of spicules or scales of
new bone on the periosteal surfaces and at the attachment of the capsular and
other ligaments.

Terminations and Sequela} of Tuberculous Diseases of Joints. — The disease
may cure at any stage, the tuberculous tissue being replaced by healthy
connective and scar tissue. Eecovery is apt to be attended with impair-
ment of movement even in mild forms of the disease. This may depend
upon limited adhesions, or upon ankylosis, or upon contraction of the peri-
articular structures. Encapsulated caseous foci in the interior of the bones
may remain latent indefinitely, or may be the cause of a relapse of the
disease at any future period. Elongation of the shafts of the bones of the
affected limb may result from the stimulation of 'growth at the epiphysial
junctions, but it is much rarer than in the staphylococcus osteomyelitis of
young children. Interference with growth is more common ; it may in-
volve only the epiphysial junctions in the immediate vicinity of the joint
affected, or it may involve all the bones of the limb ; this is well seen in
adults who have suffered from disease of the hip in childhood, — the entire
limb, including the foot, may be shorter and smaller than the corresponding
parts of the opposite side.

Atrophic conditions are also met with from prolonged disuse of the
limb ; the bones may undergo fatty atrophy, with enlargement of the
medullary canal, and marrow spaces, and thinning of the rigid framework ;
in extreme cases the bones may be cut with a knife or may sustain spon-
taneous fracture. This is to be borne in mind in forcible manipulations of
stiff joints. These atrophic conditions are recovered from when the limb
resumes its normal functions.

Relative Frequency of Tuberculous Disease in different Joints. — Available
statistics enable us to place the various joints in the following order of
frequency : spine, knee, hip, ankle and tarsus, elbow, wrist, shoulder. It is
probable that the frequency in the joints of the upper extremity is under-
stated, because the subjects thereof are often treated as out-patients and do
not figure in the statistics.

Relative Frequency of different Joints at different Ages. — While the wrist
and shoulder are rarely affected in children, disease of the hip and spine is
essentially a disease of childhood and youth, and rarely commences after the
skeleton has attained maturity. Disease of the knee, while very common
in children, may be met with at any period of life. The elbow and ankle
exhibit little age preference, but are chiefly affected during childhood and
youth.

Clinical Features. — These vary indefinitely with the different anato-
mical forms of the disease, with the joint affected, and with the individual
tendencies of the patient. The symptoms do not always correspond with
the nature and severity of the tuberculous lesions.

The onset is usually insidious, its date uncertain, and often misstated by
the patient. Sometimes the disease is ushered in with fever and with pains
in several joints before settling down in one or other joint. This method
of onset was described by John Duncan under the title of " Tuberculous
arthritic fever." It has frequently been mistaken for rheumatic fever, from
which it may usually be distinguished by the absence of any real migration
from joint to joint, the absence of sweating, of visceral complications, and

14 JOINTS, DISEASES OF

the failure of salicylates to influence the progress of the disease. The
formation of a cold abscess or the presence of a sinus may afford valuable
corroboration of the tuberculous nature of the lesion.

While it is the rule for tuberculosis to affect one joint it may involve
several, either simultaneously, as above described, or one after another.

The initial symptoms may be those associated with the presence of a
focus in the neighbouring bone ; such an osseous focus may be hidden for
years, perhaps causing neuralgic pains in the joint, and suggesting a diag-
nosis of hysteria, or the complaint may be of weakness, tiredness, stiffness, and
inability to use the limb ; the symptoms improve with rest and relapse after
exertion. These symptoms may be erroneously interpreted until the diag-
nosis is cleared up by the rupture of the focus into the joint. Buried foci
in the trochanter and in the neck of the femur may give rise to most of the
symptoms of hip disease without actual infection of the joint. Even large
caseous foci may exist for long periods without infecting the joint, from
which they may be only separated by the articular cartilage. It is rarely
possible to recognise these buried foci in the vicinity of joints by external
examination ; if they are near the surface in a superficial bone, such as the
head of the tibia, there may be local thickening of the periosteum, cedeina,
pain, tenderness on pressure and on percussion; large soft foci might be
revealed by the X-rays ; the patient may not be seen until the formation
of an abscess and of a sinus, or, still more unfortunately, until the focus
has ruptured into the joint. It is of great practical importance to recognise
such buried foci, for by treating them promptly and radically joint disease
may be prevented.

Tuberculous joint diseases are nearly always insidious in development
and chronic in progress ; they occasionally follow an acute course, resembling
that of the " acute arthritis of infants " of pyogenic origin ; this has been
observed in very young children, especially in the knee, the lesion being
synovial in origin and attended with the accumulation of pus in the joint ;
if treated promptly by incision recovery is rapid, and free movement of the
joint may be preserved.

The onset and initial progress of the disease is more often insidious, and
is attended with so few symptoms that it may have obtained a considerable
hold over the joint before it attracts definite notice. After some extra use
of the limb or some slight injury the disease becomes more active ; it is
customary for patients or their friends to attribute the disease to such an
injury. The symptoms may subside under rest, only to relapse again with
use of the limb ; there may be successive improvements and relapses in the
course of months or years. The milder forms of synovial tuberculosis may
entirely recover ; the severer bone lesions tend to cause persistent, relapsing,
and more aggravated forms of joint disease. In the absence of other
evidences of the presence of bone lesions their existence may be inferred
from the. mere persistence of the disease. In addition to the well-known
symptoms OF joint disease, such as pain, swelling, and heat, attention must
be specially directed to the wasting of muscles, the impairment or loss of the
normal movements of the joint, and the development of abnormal attitudes
of the limb. The wasting of the muscles is a constant accompaniment of
tuberculous joint disease ; it is attributed to want of use and to an influence
reflected from the trophic centres in the spinal cord ; it is especially well
seen in the extensor muscles of the thigh in disease of the knee, and in the
deltoid in disease of the shoulder; the affected muscles become soft and
flaccid, and exhibit tremors on attempted movements and a diminution of
reaction to the faradic current ; the muscular tissue may be largely replaced

JOINTS, DISEASES OF 15

by fat. The impairment or loss of the normal movements varies in degree
according to the nature and seat of the disease. In the early stages of
synovial tuberculosis the movements may be merely restricted in range and
in quality. In the case of the joints of the lower extremity there is
usually a limp in walking. When the articular surfaces are involved, all
movements, whether active or passive, are usually abolished, and the con-
dition presented is one of fixation or rigidity ; this results from involuntary
contraction of the muscles ; it disappears under an anaesthetic and returns
again on waking. Its recognition is of great diagnostic value, especially in
such deeply-seated joints as the shoulder, hip, and in those of the spine.
Abnormal attitudes of the limb may precede other symptoms of joint disease,
but are more frequently of later development ; they are best illustrated by
the well-known attitudes assumed in disease of the hip and knee (q.v.). Their
production was ascribed by Bonnet to increased pressure within the joint
and distension of the capsular ligament ; their real cause is the reflex or
involuntary contraction of the muscles acting on the joint, with the object
of placing it in an attitude in which there will be least suffering. Certain
groups of muscles, e.g. the flexors at the knee, the flexors and abductors or
adductors at the hip, assume the upper hand, either because they are more
powerful or because they are specially thrown into contraction. These
attitudes disappear under chloroform unless secondary changes have
occurred causing contracture or ankylosis. In very indolent and mild
cases these abnormal attitudes may be absent altogether. They occur
earlier, and are more pronounced in cases in which pain and other irritative
symptoms of articular disease are well marked. With the lapse of time
these attitudes may not only become exaggerated, but may become per-
manent deformities from changes within the joint in the direction of
ankylosis, and from changes in the surrounding soft parts, e.g. shortening or
contracture of the ligaments, muscles, fascia?, skin, and it may be also in the
vessels and nerves. The occurrence of startings at night, which are frequently
met with in the stage of muscular fixation, are the result of the sudden con-
tact and jarring of the diseased articular surfaces when the muscles are
relaxed during sleep ; they are to be regarded as indications that the disease
of the articular surfaces is progressive. They are more often met with in
cases which go on to suppuration.

The formation of abscess is one of the commonest accompaniments of
tuberculous joint disease ; it may appear early and play a prominent part in
the clinical features, or it may develop long after the original disease has
settled down ; it usually indicates the existence of a persistent lesion, and
very often an osseous focus of some importance. It is said to be met with
more often in patients with an inherited predisposition to tuberculosis, in
those with multiple lesions of the skeleton, and in those who are run down
and emaciated. The formation of the abscess is often attributed to a slight
injury ; it develops so insidiously that it may not attract the attention of
the patient until it has attained a considerable size ; this is especially the
case with the abscesses which are associated with disease of the spine, pelvis,
and hip. The abscess presents itself at definite situations in relation to the
different joints, the selection being influenced by the anatomical relation-
ships of the capsule and of the synovial membrane to the surrounding
tissues. The bursse and tendon sheaths in the vicinity may influence the
direction of spread of the abscess and the situation of the resulting sinus or
sinuses. It will be referred to under treatment that the formation of
abscess in the course of tuberculous joint disease may sometimes be an
advantage, for it may render a tuberculous focus more amenable to treat-

16 JOINTS, DISEASES OF

ment, especially by the injection of iodoform. When left to itself, however,
or when opened without precautions, abscess formation implies the risk of
pyogenic infection, of persistent discharge, aggravation of the associated
joint disease, progressive impairment of the general health, and greater
liability to tuberculous meningitis. It was formerly possible to observe
how often the course of the disease was altered for the worse, the inflam-
matory symptoms became more acute, the pain greater, the fever higher, the
swelling increased, the skin over the joint red, hot, and cedematous, and the
discharge coming to resemble ordinary pus.

When sinuses have been allowed to form, their course is often so tortuous
that it may be difficult or impossible to pass a probe down to the focus from
which the abscess took its origin. Infection of the lymphatic glands of the
limb is exceptional; it may, however, follow upon infection of the skin
around the orifice of a sinus.

The occurrence of pyrexia in tuberculous joint disease is usually an indi-
cation of the local progress of the disease in the direction of suppuration, or
of the development of complications elsewhere in the body ; including dis-
semination of the tubercle, e.g. to the lungs, membranes of the brain, etc.
A little rise of temperature in the evening may be induced in quiescent
joint lesions by any mechanical disturbance of the tissues involved, by
travelling or other exertion, by injury, by movement of the joint under
chloroform for purposes of diagnosis, or for the correction of some abnormal
attitude or deformity. The development and progress of an abscess may
also be attended with an evening rise of temperature ; when the abscess is
quiescent the temperature usually remains normal. A carefully taken
temperature chart may afford useful information as to the formation or
spread of abscess. When sinuses have formed and have been allowed to
become septic, there may be a diurnal variation in the temperature of the
type known as hectic fever.

Clinical Types of Tuberculous Joint Disease

1. Tuberculous Hydrops.

2. Cold Abscess or Tuberculous Empyema.

3. White Sivelling.

4. Tuberculous Arthritis.

5. Caries Sicca.

1. Hydrops tuberculosis is the name given to that form of tuberculous
joint disease in which the outstanding feature is the accumulation of serous
fluid within the joint. It is analogous to the ascitic type of peritoneal tuber-
culosis. It is most often met with in the knee of young adults. Inasmuch
as it frequently terminates in recovery with a useful joint it may be regarded
as the least serious form of tuberculous joint disease. It will be further
described under " Knee-joint, Diseases of."

2. Cold abscess ; empyema of joints is the name given by Konig to that
form of tuberculous joint disease in which the outstanding feature is the
accumulation of pus in the joint. It is analogous to the purulent type of
peritoneal tuberculosis. Its clinical features will be described under
" Knee- Joint, Diseases of."

3. Wliite Sioelling of Joints {Synovial Fungus). — Tumor albus is the name
originally applied by Wiseman in 1676 to that form of tuberculous disease
which is characterised by the gradual development of a solid swelling in the
area of a joint. The swelling is to a considerable extent the result of reactive
and mucoid changes in the fat and connective tissue surrounding the capsule

JOINTS, DISEASES OF 17

of the joint, as well as to tuberculous thickening of the synovial membrane.
It is not to be regarded as a distinct pathological type of tuberculous joint
disease, for it may originate from primary tuberculosis of the synovial mem-
brane as well as from disease in the bone, while the changes within the joint
and the course of the disease, necessarily vary within very wide limits ; at
the same time, the appearances of white swelling bulk so largely in the
clinical features of a large number of cases of tuberculous joint disease that
it is probably the best known clinical type. It is only recognised in joints
which are superficial, viz. the knee, ankle, elbow, and wrist. White swelling
of the hip or shoulder is not described. The initial symptoms are those of
swelling rather than those of implication of the articular surfaces, even
although the disease may have originated in the bone. The swelling
develops gradually and painlessly, obliterating the bony prominences and
outlines by filling up the natural hollows ; the overlying skin is white ; the
swelling appears greater to the eye than is borne ' out by measurement,
because of the wasting of the muscles above and below the joint ; in the
early stage the swelling is elastic, doughy, and non-sensitive, and corre-
sponds very accurately to the superficial area of the synovial membrane
involved; appearing at first over the cul de sac or recess of the synovial
membrane, and later over the interval between the bones. At this stage
there is comparatively little complaint on the part of the patient, for the
articular surfaces and ligaments are still intact ; there may be a feeling of
weight in the limb ; in the case of the knee and ankle the patient may tire
on walking, and drag the leg with more or less of a limp ; passive movements
are comparatively free and painless, although usually limited in range. The
disability of the joint is increased by use and exertion, and improves under
rest, for a time at any rate. As the disease progresses the signs and symp-
toms become slowly exaggerated ; the skin over the joint becomes tense and
hot, the swelling, which was at first solid, may show areas of softening, and
later of fluctuation, and a cold abscess may form, may burst, and result in
one or more sinuses. The wasting of muscles becomes more marked, the
joint becomes more rigid as the articular cartilages become affected, and the
attitude of flexion is very commonly assumed, more especially in the case
of the knee. Startings at night indicate the occurrence of destructive
changes in the articular surfaces. The final condition is one of dis-
organisation of the joint, with deformity and septic sinuses.

4. Tuberculous Arthritis. — It is convenient to group under this heading
those cases of tuberculous joint disease in which the outstanding clinical
features are the result of implication of the articular surfaces. Although
as already indicated, these symptoms commonly develop in the later stages
of white swelling, it is a matter of every day experience that symptoms of
implications of the articular surfaces may be the first evidences of tuber-
culous joint infection, and may exist without white swelling or any other
clinical evidence of disease in the synovial membrane. These remarks
specially apply to such deeply-seated joints as the hip, shoulder, and spine,
which never present the phenomena of white swelling, but they are also
applicable to other joints. The recognition of this arthritic form of tuber-
culous joint disease depends rather upon inferences founded upon certain
symptoms and signs than upon direct examination of the joint concerned.
The patient complains of pain at the site of the disease, or he refers it to
some other part with which it is connected through the nerves ; the pain
is aggravated by movement and by the manipulations of the surgeon ; in
the case of the joints of the lower extremity the patient will limp in walk-
ing ; the movements of the joint are restricted, very often to the extent of
VOL. vi 2

18 JOINTS, DISEASES OF

fixation or rigidity. The recognition of rigidity is one of the most valuable
evidences in the diagnosis of disease at this early stage, especially in
deeply-seated joints. The wasting of muscles is more marked than in the
early stage of white swelling. Very commonly the limb is placed in an
abnormal attitude by the contraction of special groups of muscles ; these
attitudes are well illustrated in disease of the hip. If the disease is left to
itself and progresses, all the other well-known signs of joint disease may
make their appearance, e.g. startings at night, the formation of abscess and of
sinuses, displacement or even dislocation of the bones; until under an
anaesthetic the joint may be found to be completely disorganised, with de-
struction of ligaments, abnormal mobility, and grating of the articular
surfaces.

5. Caries sicca is the name given by Volkmann to a very chronic form
of tuberculous arthritis, chiefly met with in the shoulder and hip of adults
between the ages of fifteen and thirty-five. There is an entire absence of
swelling. The wasting of all the structures in the vicinity of the joint is
characteristic ; the bony prominences, such as the acromion and coracoid in
the case of the shoulder and the trochanter at the hip, stand out prominently.
Passive movements are very restricted and are attended with severe pain.
The general health usually remains unimpaired in spite of the long duration
of the disease. In exceptional cases an abscess may form ; it is usually
small and extra-articular, and is related to a sequestrum.

Krause has observed cases in which, after many years of indolent pro-
gress, there has developed without any apparent cause the most acute
suppurative and destructive changes in the joint, necessitating operation
without delay ; in excising the joint it is found that the head of the bone
may have almost or entirely disappeared, and that the tissue of the neck is
dense and sclerosed, proving conclusively that the disease was really one of
long standing.

Influence of the Joint Disease on the General Health. Causes of Death. —
While experience shows that tuberculous joint disease may be compatible
with good general health, the tendency is for it to be affected when the
disease is serious and persistent. Sherman has observed in children a
diminution of the red blood corpuscles and of the haemoglobin. Dane has
observed leucocytosis when an abscess is forming and when septic infection
is superadded. The appetite is impaired. The patient is easily tired and
complains of loss of strength, especially when there is fever. The skin is
dry. The loss of flesh may amount to emaciation. Albuminuria is a
frequent accompaniment of joint lesions which are. suppurating ; it usually
results from waxy disease of the kidneys, but may be a sign of parenchy-
matous nephritis ; general dropsy is a more unfavourable indication of the
interference with the renal functions. A considerable number die from
exhaustion with all the accompaniments of hectic fever. Tuberculous
disease of the lung is very frequent in the case of adults ; it may be present
at the time when the joint disease begins, or it may appear later. Tuber-
culous disease of the intestine is not uncommon. In the case of children
acute miliary tuberculosis is more common than either, and is usually
rapidly fatal; it may occur without apparent cause, or it may follow
immediately on operative interference (comparatively trifling operations,
e.g. scraping of sinuses) ; the clinical features are frequently those of basal
meningitis.

The Diagnosis of Tuberculous Joint Disease. — The family history,
the presence or history of tuberculous lesions elsewhere in the body, the
insidious onset, the fact that there is usually an interval between the

JOINTS, DISEASES OF 19

appearance of symptoms and the receipt of an alleged injury, all suggest
the tuberculous origin of any given case of joint disease. The diagnosis is
usually quite easy in typical cases. One should not be misled by the age
of the patient or by the appearance of excellent health. The X-rays are
chiefly of value in the recognition of osseous lesions. The details of
differential diagnosis are beyond the scope of the present article. The use
of Koch's tuberculin is not recommended.

Prognosis. — This is not easily stated in general terms, since it varies
with the seat, extent, and severity of the local disease, and with the resisting
powers of the patient as influenced by the general health, age, and social
circumstances. Eecovery is never impossible. The existence of tuber-
culous lesions elsewhere and the formation of septic sinuses are unfavour-
able factors. While tuberculous lesions in children tend to become circum-
scribed, in adults the tendency is in the opposite direction. The absence
of any response to conservative treatment is unfavourable. The locality of
the disease is an important factor ; in the limbs the hip joint is the most
serious of all, because there is greater difficulty in treatment, and the disease
is often of a serious type, and may be attended with pelvic complications.

The patient and his friends must be informed of the length of time
required for complete recovery ; it necessarily varies, but it may be stated
generally as being from one to three years. The risk of relapse at some
future period of life must not be forgotten.

Treatment. — In addition to that applicable to all forms of tuberculosis
(hygienic, dietetic, etc.), we are here concerned with the local measures
directed towards the disease in the joint and its concomitants. These may
be described under two heads, the conservative and the operative.

Conservative Treatment. — This is almost always to be employed in the
first instance, and only when it fails is recourse to be had to operative
methods, since with the former a large proportion of cures are obtained with a
less mortality, and the functional results are better than those obtained by
operation. The essentials of conservative treatment include the placing
of the joint at complete rest, the correction of abnormal attitudes, the pro-
duction of venous congestion, and the injection of iodoform; all these
may not be applicable in every case.

The treatment by rest implies the immobilisation of the diseased limb until pain
and tenderness have disappeared. It is carried out by means of bandages, plaster
of Paris splints, or other apparatus according to the joint affected. The attitude
in which the limb is immobilised should be that in which, in the event of
subsequent stiffness, it will be most serviceable to the patient. Extension with the
weight and pulley is a valuable adjunct, especially in disease of the hip or knee ;
it eliminates muscular spasm and the pressure of the articular surfaces against one
another ; it relieves pain and startings at night ; it prevents abnormal attitudes
of the limb, and may bring about their disappearance, provided they are not
associated with organic changes which render them permanent. The question of
abnormal attitudes is discussed in the special articles on the hip and knee, but it
may be stated generally that if the limb is in a deformed attitude when the patient
first comes under observation, and it does not readily yield to extension, it should
be corrected straight away under an anaesthetic. The permanent deformed
attitudes which are due to contraction of the soft parts around the joint or to
ankylosis will be considered later.

The injection of iodoform, if carried out efficiently, is of great value. The
preparation employed is a 10 per cent emulsion of powdered iodoform in glycerine,
which becomes " sterile " soon after it is made. Its curative effects would ajjpear
to depend upon its antiseptic properties, which although slight, continue in action
for weeks or months, and upon its capacity for irritating the tissues and stimu-
lating the formation of scar tissue. The usual antiseptic precautions are im-
perative. An anaesthetic is rarely called for.

20 JOINTS, DISEASES OF

If it is proposed to inject the cavity of an abscess the contents are first evacuated
through a medium sized trocar, introduced obliquely, avoiding any part where
the skin is thin or red. If the trocar is blocked with caseous material it must be
cleared with a probe. The iodoform is injected by means of a glass barrelled
syringe which will screw securely on to the trocar. The amount injected varies
from 4 cc. in small children to 30 cc. or more in adults. The puncture is covered
with a pad of gauze, and a dressing is applied which will exert a certain amount
of compression.

If it is preferred to make an incision into the abscess (and this may be necessary
where the contents are semi-solid, or may be indicated when it is intended to
clear out a localised focus in the bone) the cavity is emptied, and the iodoform
is injected through a rubber tube attached to the syringe, simultaneously with
the closure of the wound by sutures, so that the cavity when closed will be dis-
tended with the emulsion. If the abscess wall has been scraped with the spoon a
less amount of iodoform is injected, as the drug is more likely to be absorbed.
The method is unsatisfactory unless the wound heals by first intention.

The iodoform injection may require to be repeated after an interval of three to
six weeks ; the author has, however, repeatedly cured retro-pharyngeal, lumbar, and
psoas abscesses by a single injection, sometimes through the trocar, sometimes
through an incision.

If it is ])roposed to inject the iodoform into the joint the procedure varies with the
nature of the lesion. In cases of hydrops and of empytema the method is the same
as in abscess, and is easily carried out, especially in the knee. The sites to be
selected for injecting the different joints are as follows : (Krause) wrist, just below
the radial or ulnar styloid process; elbow, just above the head of the radius;
shoulder, either outside the coracoid or at the junction of the acromion with the
spine of the scapula ; ankle, below either malleolus, then direct the trocar
upwards ; knee, by way of the suprapatellar pouch, or between the bones at the
inner side of the ligamentum patellae ; hip, see " Hip Joint, Diseases of." When
the joint is not distended with fluid, e.g. in white swelling, the conditions for dis-
tributing the iodine are less favourable. In the knee, the joint may be divided up
into compartments by septa of connective tissue derived from the synovial mem-
brane, and the iodoform must be introduced into all of them. The trocar must
be thrust in all directions, successive parts of the joint being attacked at
different sittings, and the injections must be repeated more frequently and at
shorter intervals (10 to 14 days). Opinion is divided on the question of massage
and gentle passive movements with the object of distributing the iodoform ; some
believe that this entails the risk of disseminating the tubercle bacilli. Injections
into the substance of the synovial membrane (parenchymatous injections) are less
certain, are more painful, and require greater pressure on the piston of the
syringe. Mikulicz and others attempt to inject the iodoform into the adjacent
bones when they are soft enough to allow of the entrance of the trocar. Wherever
the iodoform is introduced it remains for long periods, and may be seen as a dark
shadow in skiagraphs.

After any form of iodoform injection, one must be prepared for considerable
reaction, attended with fever (101° F.), headache, malaise, and it may be sickness
for from one to three days, and considerable pain and swelling of the joint. The
reaction diminishes with each subsequent injection.

When an abscess has ruptured and left a simts, an olive-shaped nozzle must be
attached to the syringe which will completely close the orifice of the sinus and
prevent the immediate escape of the emulsion, which must be forced into the
sinus ; the orifice of the latter is closed with the finger for ten minutes ; it
will then be found that only a little clear glycerine escapes ; pads of gauze are
applied, and the procedure repeated two or three times a week. The results are
very good if the sinus is not already septic. Septic sinuses are better laid open,
sterilised, and made to heal from the bottom by the open method. It is main-
tained that even the existence of sequestra is not an obstacle to the success of the
iodoform treatment, for if they are thoroughly soaked in iodoform and glycerine,
the bacilli may be exterminated and the sequestra may become encapsulated
by connective tissue.

The artificial production of venous congestion, introduced by Bier, is an im-
portant adjuvant to the iodoform treatment. To be successful it must be efficient and
carefully supervised. An elastic webbing bandage (two or three turns) is applied
outside a layer of lint immediately above the affected joint, sufficiently tightly to
constrict the veins and produce a bluish red tinge of the skin. Below the joint
the limb should be bandaged to prevent oedema. The site of application of the

JOINTS, DISEASES OF 21

elastic bandage should be changed frequently so as to avoid maceration of the
skin and diminish the tendency to wasting of the muscles. It may be worn con-
tinuously, but the intermittent application is better, from 14 to 18 hours each day ;
in the interval the oedema around the joint may be dispelled by a bandage._ The
venous congestion appears to act beneficially by stimulating the formation of
connective tissue. It has been objected to by some surgeons because under its
influence latent tuberculous foci have been transformed into cold abscesses ; this
is no drawback, since the cold abscess is more amenable to iodoform treatment
than the latent focus. The congestion should be persevered with, in suitable
cases, until a month or two after the joint disease appears tohave been cured.
The congestion should be omitted for two or three days after iodoform has been
injected. The congestion treatment is not applicable to the hip or shoulder.

Under the combined influence of rest, iodoform injections, and venous congestion, if
the disease of the joint undergoes cure the pain and tenderness subside, passive
movements become possible, and the swelling gradually subsides ; it is a favour-
able sign if the swelling becomes harder and firmer. In the later stages of treat-
ment the patient is encouraged to remain in the open air ; in the case of the
lower extremity the limb must be maintained in a good attitude, and should not
be allowed to touch the ground. In the evening, the limb should be washed,
massaged, gently exercised, and the wasted muscles may be stimulated with
electricity.

The results obtained by the foregoing methods of conservative treatment, along
with attention to the general health, are in the majority of cases extremely
satisfactory. The best and most certain results are obtained in children.
Apparently permanent cures are obtained in cases which were formerly subjected
to all kinds of severe operative interference. It is unfortunate that we can rarely
tell beforehand whether it is certain to succeed, or how long the cure will take.
An exception must be made in disease of the knee joint in adults ; opinion is be-
coming unanimous that if there is no prospect of obtaining a movable joint by
conservative measures, it is better to have, recourse to excision in the first
instance, for thereby one may guarantee the best obtainable functional result with
the minimum expenditure of time. In other joints the conservative treatment is
only abandoned if the disease continues to progress in spite of it, if improvement
does not show itself after a thorough trial, or if the disease relapses after_ apparent
cure {vide indications for operative interference). The external application of
iodine or of mercurial ointment (Scott's dressing) is of doubtful value ; the fly
blister and the actual cautery have largely gone out of fashion,_ but they may be
employed with benefit for the relief of pain when this is a prominent feature.

Operative Treatment : the indications for operative interference vary in
each case ; they are more restricted than was the case during the era when
Listerian methods first eliminated the septic complications of wounds. So
far as the general condition of the patient is concerned, age is an important
factor. Other conditions being equal, operation is more often required in
adults, because after the age of twenty there is less prospect of spontaneous
recovery, there is more tendency to relapse and to tuberculous disease of
the internal organs, and there is no fear of interfering with the growth of the
skeleton. The general health may necessitate the removal of the disease
by the most rapid method, viz. by operation.

The social status must, unfortunately, be taken into account ; the bread-
winner, under existing social conditions, may be unable to give up his work
for a sufficient time to give conservative measures a fair trial.

The local conditions which decide the question for or against operations
are differently regarded by each individual surgeon. They may be
expressed in general terms, for those who have no personal experience to
guide them, as follows : — Operative interference is indicated (1) In cases
where, in spite of a fair trial of conservative measures, the disease continues
to progress ; (2) In cases unsuited for conservative treatment, e.g. where
there is dislocation, separation of epiphysis, or deformity incapable of being
rectified otherwise, when there are sinuses with septic infection, and the
operation affords a reasonable prospect of getting rid of both the tubercu-

22 JOINTS, DISEASES OF

losis and the sepsis, and when the disease is associated with severe bone
lesions (e.g. large sequestra, central abscess of bone), or threatened with
infection of the lymphatics ; (3) In cases where the results of operative
interference will be as good or better than those likely to be obtained by
conservative measures ; this has been already discussed in relation to the
knee, and the advice given that if in the adult the joint is likely to be
stiff, then this result is more certainly and rapidly obtained by excision.
The same indication applies to the knee in children ; the operation performed,
however, must not entail any interference with the epiphysial discs; the
articular cartilages are pared with a strong knife instead of removing the
ends of the bones with the saw. The same indication also applies to the
elbow both in adults and in children ; if the joint is likely to be stiff, and
this result will not comply with the requirements of the patient, much
time will be saved by an immediate excision, thereby securing a movable
joint and getting rid of the disease at the same time. In other joints the
functional results obtained by conservative measures (excepting under the
conditions mentioned above) are usually superior to those following opera-
tion, they are therefore persisted in so long as there is any prospect of their
leading to a cure of the disease.

The Nature of the Operative Interference varies with the patient,
the joint affected, and the type and extent of the disease. In many cases
it can only be decided after exploration of the joint. The operative treat-
ment of the present day is different from the old method of excising
joints in which the bones were removed with the saw and the diseased soft
parts left behind. The modern tendency is not to proceed on stereotyped
lines, but to perform atypical operations directed to the special features of
each individual case. Experience is therefore an important adjunct to
pathological knowledge.

The chief aim is to remove all the disease with the least impairment of func-
tion. The sacrifice of healthy tissues is reduced to a minimum. The more open
the method of operating the better, so that all parts of the joint are available for
inspection, and the principal incision must be so planned as to achieve this
object without unnecessary damage to the essential structures of the joint and of
the overlying soft parts ; the methods introduced by Kocher comply with these
conditions, especially those which permit of dislocating the joint, since this pro-
cedure affords the freest possible access for inspection and for removal of the
disease. Cold abscesses or sinuses should be cured if possible before operating on
the joint. Diseased synovial membrane is removed with the scissors or knife,
sparing its fibrous layer if possible. If the cartilages are sound they may be left
(excepting always the knee if a rigid joint is the aim of the operation.) If the
cartilage is diseased at any point it should be removed so as to permit of inves-
tigating the bone beneath. If extensively separated it should be removed entirely,
and special attention directed to the bones. The most minute sinus in bone must
be followed up in case of its leading to a caseous focus or sequestrum. If the
surface-bone is diseased a thin slice of it should be removed with the knife or
saw. If foci are then revealed it is often better to dig them out than to remove
further slices of bone, thereby sparing the cortex and the periosteum. The un-
initiated must not mistake fatty marrow for disease.

Further details belong to the surgery of the individual joints. The limb
should be rendered bloodless before commencing the operation. The technique
should be antiseptic, rather than aseptic, so as to diminish the chances of tuber-
culous infection of the wounded surfaces ; with the same object in view, as well
as to overcome any minute tuberculous foci which may have escaped detection
and removal, a small quantity of sterilised iodoform should be rubbed into the
raw surfaces and recesses of the joint.

Closure of the entire wound without drainage may be successful in selected
cases ; inasmuch, however, as an accumulation of blood-clot affords an admirable
soil for the development of any tubercle bacilli which have been left behind, it
is safer to employ some means of preventing the accumulation of blood in the

JOINTS, DISEASES OF 23

wound ; the most reliable is to pack the wound with iodoform worsted or gauze,
bringing out the end of the strand or strands at one point of the main wound (or
through a small wound made for the purpose). If the temperature remains
normal the packing is left for a week ; it is then moistened with iodoform-
glycerine to allow of its being removed without bleeding ; a less amount of pack-
ing is then introduced, or the whole wound is rilled up with the iodoform-emulsion
by means of the injection syringe and a rubber tube, the end of which is inserted
into the deepest part of the wound ; a suture or gauze pad is then applied to
prevent the escape of the emulsion. If there is septic infection either in the first
instance or subsequently, the whole wound should be stuffed and treated by the
"open method." If a rubber drainage tube is employed to prevent the accumula-
tion of blood it should be removed in 24 or 48 hours.

Where there are sinuses they must be treated as already described. They are
often an indication for treatment by the " open method." It will be observed
that nothing has been said of the respective merits and sp)heres of arthrectomy and of
excision; the original distinction between these procedures has largely dis-
appeared ; the modern atypical operation for the cure of tuberculous joint disease
sometimes partakes of the characters of an arthrectomy, sometimes of an excision,
but in many cases neither of these terms would accurately describe the operation
which best meets the requirements of the case. A formal excision is more
often employed in the knee and elbow than in other joints, modified in the case of
children in view of the functional importance of the epiphysial junctions con-
cerned. For details the reader is referred to the articles on the individual joints.
In the after treatment of cases subjected to operation, it is essential that they should
be under direct supervision for several years, in case of a relapse of the disease,
to promote mobility where the joint is intended to be movable, and to prevent
deformities and abnormal attitudes where it is intended to be stiff or rigid.
Massage, electricity, exercises, and hydrotherapy promote the recovery of function.
When the functional result is good, the wasting and arrest of growth of the
muscles and of the limb as a whole are more likely to be recovered from.

The operative treatment of deformities resulting from tuberculous joint disease
has almost entirely replaced the former attempts by forcible reduction, because of
the unsatisfactory results and of the risks involved (fracture, separation of
epiphysis, fat embolism, lighting up of quiescent encapsulated foci, etc.) The
modern procedure is to divide the contracted soft parts by open operation, and to
divide or resect the bone where there is undesirable osseous ankylosis (see in-
dividual joints).

The treatment of relapse or recrudescence of the disease at the site of operation is
carried out on the same lines as for the original disease, and should be had re-
course to as soon as it is recognised. The same remark applies to tuberculous
disease in the associated lymphatic glands.

Amputation or disarticulation of the limb for tuberculous joint disease is becom-
ing one of the rare operations in surgery. It is only employed where recovery is
otherwise hopeless. The general health and age of the patient, and the occurrence
of local and general septic complications, are the chief determining factors.
Amputation should never be performed unless it secures a complete removal of
the disease both in the bones and in the soft parts. Other things being equal,
one has less hesitation in having recourse to amputation in the lower than in the
upper limb.

Syphilitic Diseases

These are decidedly rare as compared with tuberculous diseases, syphilis
being much more a disease of bone than of joints. It is probable that their
rarity has been over-estimated, because they are not always correctly diag-
nosed. As in tuberculosis, they may be primary in the joint, or secondary
to disease in the adjacent bones. In acquired syphilis the joint affections
may be described as early and late.

(i.) The early lesions occur in what is conveniently described as the
secondary period. They may assume the form of an arthralgia, correspond-
ing to the bone pains, and affecting the shoulder, knee, wrist, or ankle ; the
joint becomes sensitive and painful, and the pain is worst at night. There
are no organic changes in the joint.

They may assume the form of a serous synovitis, sometimes called

24 JOINTS, DISEASES OE

syphilitic rheumatism, from its resemblance to polyarticular rheumatism ;
the joint or joints become swollen, hot, and painful, and there may be a
certain amount of fever, or of a hydrops, which is met with almost exclusively
in the knee ; it is frequently bilateral ; it is very insidious in its onset and
progress ; the patient may be able to go about ; if untreated it may last
for months.

Both the synovitis and the hydrops may closely resemble the correspond-
ing lesions resulting from gonorrhoea ; they rapidly and completely dis-
appear, however, under syphilitic treatment.

(ii.) The late or tertiary lesions of joints are much more persistent and
destructive ; they result from the formation of gummata in the extra-arti-
cular tissues, either in the deeper layers of the synovial membrane or in
the adjacent bone or periosteum ; this explains the absence of articular
symptoms in the early stages ; in the majority of cases severe joint symptoms
do not develop unless as a result of breaking down of the gummatous tissue
and the addition of septic infection.

Perisynovial and peribursal gummata are most often met with in rela-
tion to the knee joint of adults of middle age, and especially of women ;
the gummata are usually multiple, they develop very slowly, and may be
unattended with any symptoms ; they are rarely sensitive or painful ; in
the working classes the patient may not apply for advice until the gumma
has broken down and given rise to a tertiary ulcer. The simultaneous
presence over the knee joint of indolent swellings, of ulcers, and of depressed
scars is very characteristic. When the gummata do not break down, the
resemblance to the white swelling of tuberculous origin may be considerable;
attention should be directed to the nodular, uneven, irregular character of
the gummatous affection ; sometimes the skin is red and tender over a
gumma without the decided liquefaction and fluctuation which would
accompany reddening of the skin in a tuberculous lesion.

Effusion into the joint is rarely a prominent feature. The gummatous
nodules when close to the synovial lining may project into the interior of
the joint ; it may be like the fringes in arthritis deformans, and have been
known to give rise to the symptoms of " loose body."

Eecovery may be attended with considerable stiffness and contracture
deformity.

Gummata in the periosteum or marroiv of the adjacent bones may result
in a form of joint disease known as syphilitic osteo-arthritis. There is a
gradual enlargement of one or other of the bones, attended with neuralgic
pains which are worst at night ; at this stage the diagnosis from sarcoma
may be difficult or impossible ; the gummatous disease may extend to the
synovial membrane, and may be attended with effusion into the joint, or it
may erupt on the periosteal surface and break through the skin, forming
one or more sinuses. The further progress in untreated cases is complicated
by the occurrence of septic infection and of necrosis of bone. In the knee
joint, the patella or one of the condyles of the femur or tibia may furnish
a sequestrum, which may involve the articular surface and impart to the
disease a persistent and destructive character. In such cases one should
not expect recovery from antisyphilitic treatment alone, it must be sup-
plemented by operative measures directed to the removal of the damaged
tissues ; excision of the knee is rarely called for, even in the most aggravated
cases ; in the elbow it may be practised in order to obtain a movable joint.

In inherited syphilis the earliest joint affections are associated with the
epiphysitis (or syphilitic osteo-chondritis) of young infants ; there may occur
some effusion into the adjacent joint (knee, elbow); in exceptional cases

JOINTS, DISEASES OF 25

pyogenic infection may be superadded, and the joint may fill with pus. In
children a serous synovitis or hydrops may develop in the knee of one or
of both sides, sometimes in the earlier period, along with iritis, or at a later
period along with interstitial keratitis ; it is very chronic, and scarcely causes
any symptoms. It disappears under treatment without any impairment of
the functions of the joint. The tertiary or gummatous lesions of joints are
the same as have been described as met with in the subjects of acquired
syphilis; they are most often met with in relation to the joints of the
fingers in syphilitis dactylitis, but are also met with in the knee and elbow.

III. Joint Diseases accompanying certain Constitutional

Conditions

Gout.

Chronic Articular Rheumatism.

A rthritis Deformans.

Arthritis Ossificans.

HoeTnophylia.

The gouty affections of joints are considered in the general article on
" Gout " (vol. iv.) Their surgical importance relates to the differential
diagnosis and to the occasional necessity for operative interference.

Chronic rheumatism is an ill-defined affection of joints which is chiefly
remarkable for the amount of suffering to which it may give rise, and the
great disturbance in the functions of the joint which may result from it.
Its claims to be called rheumatic rest upon the following facts : it usually
follows upon acute articular rheumatism; it may show exacerbations or
relapses, attended with pyrexia and relieved by salicylates ; it is met with
in patients who present a family history of acute rheumatism or of inflam-
mation of serous membranes; there may be a history of chorea, or of
erythema nodosum, or of rheumatic nodules, or other undoubted evidences
of rheumatism.

It is usually polyarticular. It may be met with in childhood and youth
as well as in adults. The primary changes in the affected joints almost
exclusively involve the synovial membrane, the ligaments, the surrounding
tendon sheaths, and bursse ; they consist in inflammatory infiltration and
exudation, resulting in the formation of new connective tissue, which
encroaches on the cavity of the joint and gives rise to adhesions. The
newly - formed connective tissue tends to contract, causing deformity
and stiffness. Changes may occur in the articular cartilages secondary to
adhesions between opposing surfaces, or as a result of their displacement, so
that they are no longer in contact with one another ; they consist in the
conversion of the cartilage into connective tissue. The bones are only
affected in so far as they undergo fatty atrophy from disuse, or alteration
in their configuration as a result of displacement (subluxation). Sup-
puration does not occur. Osseous ankylosis may be observed, especially in
the small joints of the hand and foot.

Clinically the disease is chronic and often incurable. Pain may be so
prominent a feature that the patient resists the least attempt at movement.
In other cases the joints, although stiff, may be moved, and exhibit pro-
nounced crackings. The joints are enlarged or swollen when there is much
new connective tissue formed in relation to the synovial membrane ; the
swelling becomes more noticeable as the muscles waste above and below the
joint. Subacute exacerbations occur from time to time, with fever and with
aggravation of the local symptoms and signs. While recovery may take

26 JOINTS, DISEASES OE

place with ankylosis and deformity, the patient becoming a helpless cripple,
the tenure of life is very uncertain because of the tendency to visceral
complications.

Erom the nature of the disease treatment is very rarely curative. Sali-
cylates are only of service during the exacerbations attended with pyrexia.
Temporary improvement may result from the general and local therapeutics
available at such places as Bath, Buxton, Wiesbaden, Wildbad, Aix, etc.
Forcible attempts to remedy stiffness or deformity are to be avoided. A
certain measure of success has followed operative interference in selected
cases, consisting in a modified arthrectomy, and the injection of an emulsion
of iodoform or guaiacol in glycerine. Deformities resulting from chronic
rheumatism are treated on the usual lines.

Arthritis Deformans, Osteo- Arthritis, Chronic Rheumatic Arthritis,
Rheumatoid Arthritis, Rheumatic Gout, Malum Senile, Traumatic or
Mechanical Arthritis. — It is impossible within the limits of the present
article to attempt to give an account of the group of joint affections which
are at present included under the above vague and misleading nomenclature.
Excluding those which are definitely gouty or rheumatic, there are provi-
sionally included under the name arthritis deformans or osteo-arthritis a
number of joint lesions which, in their etiology and clinical features, differ
from each other to such a degree that we can only explain their inclusion
in a common group by confessing that we are ignorant of their essential
nature. Among the list of names given above, we must be especially sus-
picious of those which aim at giving a clue to the origin of the disease.
Eheumatism and gout are only related to the diseases under consideration
in so far as they may precede the latter, and that arthritis deformans is
more often met with in families who are tainted with rheumatic or gouty
tendencies. The term malum senile, implying as it does an association with
the changes resulting from advancing years, is singularly inappropriate as
a general name for a disease which may be met with in childhood. The
suggestion of Arbuthnot Lane's, that the lesions under consideration are the
result of a single or repeated trauma, while ingenious and instructive, can
scarcely be accepted as conclusive.

The reader will probably agree with the author that it is easier to express
the negative in regard to arthritis deformans, than to formulate positive
views which are of any real value.

The anatomical changes are so well known that their description may
be omitted.

The clinical featukes vary indefinitely ; the following are the chief
types:— _

1. Hydrops is frequent in the knee, but may be met with m the elbow,
shoulder, ankle, etc.; the patient complains of a feeling of weight, of insecurity,
and of tiredness in the joint; pain is occasional and evanescent, and is
usually the result of some extra exertion. As .the joint fills more and niore^
with fluid the ligaments become stretched, so that the limb becomes
weak and unstable ; it may be associated with hydrops of the adjacent
bursas. The affection is extremely chronic, and may last for an indefinite
number of years. It is to be diagnosed from the other forms of hydrops
already considered, viz. the purely traumatic, the pyogenic, gonorrhceal,
tuberculous and syphilitic, and from that associated with Charcot's
disease.

The symptoms may be relieved by hydrotherapy and massage, and by
the support of an elastic bandage ; great benefit or even cure may follow
the withdrawal of the fluid and the injection of iodoform glycerine.

JOINTS, DISEASES OF 27

2. The presence of fringes and of pedunculated and other loose bodies may
give rise to characteristic clinical features, especially in the case of the knee;
they often coexist with hydrops ; the fringes, which may assume the
luxuriance of what has been described as an arborescent lipoma, project
into the cavity of the joint, and may fill up all its recesses and distend the
capsule. The joint is swollen and slightly flexed. Pain is not a prominent
feature, the functions of the joint are but little impaired, so that the patient
may walk fairly well. On grasping the joint while it is flexed and extended
by the patient the fringes may be felt moving under the fingers.

The patient may first apply for advice on account of the symptoms of
loose body, viz. sudden severe pain with temporary fixation or locking of the
joint, disappearing as suddenly as it came. The attack may recur at irregular
intervals. If the loose body is attached, the pain is located to a particular
area of the joint, if its pedicle has given way it may wander about the joint ;
in either case it may be identified by the patient, or on examination by the
surgeon. The treatment applicable to this type is the removal of the hyper-
trophied fringes or of the loose body by open arthrotomy, and is usually very
successful.

3. The dry arthritis deformans (arthritis sicca), although especially
common in the knee, is met with frequently in all the large joints, either
as a solitary or multiple disease, and it is also very common in the joints of
the spine and of the fingers, and in the temporal maxillary joint. In the
joints of the fingers in older patients the disease is remarkably symmetrical.
It tends to assume the nodular type (Heberden's nodes), whereas in younger
individuals it assumes the more crippling and painful and progressive fusiform
type. In the larger joints, e.g. knee, hip, shoulder, the subjective symptoms
usually precede any palpable evidences of disease. The patient complains
of stiffness, cracklings, and aching, aggravated by changes in the weather
and by rest. The roughness (fibrillation) of the articular cartilages may be
appreciated by the coarse friction or rubbing, on movement of the joint. It
may be many months or years before the lipping and other hypertrophic
changes in the ends of the bones are recognisable, and before the joint
assumes the deformed features which have given the disease its name.
These are referred to under the individual joints.

The three types described may occur in combination.

As regards the progress of the disease, it is usually observed that in
patients who are still young the tendency is to advance with considerable
rapidity, so that in the course of a few months it may cause serious crippling
of several of the joints. In older patients its progress is much more
gradual and intermittent, and in them the disease is compatible with long
life.

Treatment, in the absence of definite knowledge of the etiology of the
disease, is chiefly directed towards the relief of symptoms. On no account
should the affected joints be kept at rest. Passive movements, exercises of
all kinds, massage, and douching are to be steadily persevered with. When
pain is a prominent feature it may be relieved either by douches of iodine
and hot water, or by the application of lint saturated with chloral gr. v.,
glycerine 3j., water §j., or with equal parts of menthol and parolein, and
covered with oil-silk. Operative interference (arthrectomy, arthrodesis,
excision) is indicated in the large joints of the limbs when the disease is
of an aggravated type, is mono-articular, and the patient is neither old nor
unhealthy.

A course of treatment at one of the reputed baths, e.g. Aix, Bath,
Buxton, Gastein, Wiesbaden, Wildbad, is often of great service.

28 JOINTS, DISEASES OF

The patient should be well nourished. There should be no restriction,
such as is required in gouty patients, so long as the digestion is not impaired.
Benefit is also derived from the administration of cod -liver oil and of
tonics.

Arthritis ossificans is the name applied by Griffiths of Cambridge to a
condition in which the joints affected become obliterated as a result of fusion
of the bones with one another. The cancellous tissue of the one becomes
directly continuous with the other without any trace of separation across
what was originally the joint cavity. The disease usually begins in the
early years of adult life. It is more often met with in men. It is slow in
its progress, inasmuch as years elapse before the joints become rigid. It is
polyarticular, one joint being affected after another. It may involve all the
joints of the body. Its origin is unknown.

ELemophylia— H^emarthrosis — Bleeders' Joint

Although described in the article on " Hsemophylia," in vol. iv., it may be
useful to refer to the clinical features of bleeders' joint so as to bring out
the contrast between it and other diseases of joints. The subject is usually
a boy or youth, who, without any definite injury, presents a rapid effusion
into a joint, usually the knee. There is little pain. The temperature may
be considerably elevated (102° F.) The patient frequently exhibits ecchy-
moses or swellings on other parts of the body, so that he should be completely
stripped for purposes of examination. After a single haemorrhage into the
joint the blood is reabsorbed, especially under the influence of gentle massage
and passive movements. After repeated attacks, however, secondary changes
occur, associated with the persistence of blood-clot and its partial organisa-
tion, and the joint may become uniformly swollen and stiff, so that the
resemblance to white swelling may be so close that a mistaken diagnosis
has been made by experienced observers, and an operation has been performed
which has cost the patient his life. The treatment consists in the maintenance
of rest, the application of cold and of compressing bandages when the hsemor-
rhage is recent. After an interval the use of massage and of gentle passive
movements promotes the absorption of the blood and hinders or prevents
the occurrence of stiffness.

IV. Joint Diseases associated with Lesions of the Nervous System
— Neuro-arthropathies — Spinal arthropathies — Charcot's
Disease

In the absence of any proof of the existence of special trophic nerves
distributed to joints, the diseases under consideration are to be regarded as
related to ■ a disturbance of the sensory nerves which pass from the joints
to the spinal cord, whereby they are cut off from the reflex vasomotor
influence which is necessary for their proper nutrition and for their capacities
of recuperating from the effects of injury. The joints present a diminished
resistance to trauma and other external influences very similar to that
exhibited by the skin in its liability to pressure sores, perforating ulcer, and
other trophic disturbances. It may be said, therefore, that while the nerve
lesion prepares the way for the joint disease, its onset and progress are
largely dependent upon external factors, of which trauma in its various
forms is the most important. A patient whose knee joint is anaesthetic
and analgesic is not only more exposed to minor forms of injury, but he

JOINTS, DISEASES OF 29

continues to use the joint, whereas under normal conditions he would place
it under conditions favourable for repair.

(1) In Lesions of the Peripheral Nerves. — Affections have been observed
in the joints of the hand, and more rarely in those of the foot, when one or
other of the main nerve trunks has been divided or compressed. The affected
joints become swollen and painful, and may afterwards become stiff and de-
formed. Bony ankylosis has been observed in exceptional cases.

(2) In lesions of the spinal cord, excepting locomotor ataxia and syringo-
myelia, arthropathies are very rare indeed. In relation to stab-wounds and
crushes of the cord their rarity is probably the result of the rest and im-
munity from injury of the paralysed limbs. Joint lesions are also very rare
in cases of myelitis, progressive muscular atrophy, infantile paralysis, insular
sclerosis, etc.

In locomotor ataxia the occurrence of joint lesions was first described by
Charcot, hence the popular term " Charcot's disease." They occur in from
5-10 per cent of the recorded cases. Although usually developing in the
ataxic stage, one or more years after the initial spinal symptoms, they may
appear before any other evidence of tabes. Their association with injury
is generally accepted. The joints of the lower extremity are much more
commonly affected, and the disease is bilateral in a considerable proportion
of cases, e.g. both knees, both hips, etc.

The disease may assume a mild form, in which the joint and its vicinity
become swollen, either spontaneously or after some extra exertion or slight
injury. The swelling is chiefly due to fluid within the joint, and the latter
cracks or grates on movement. The affection may disappear under rest, or
persist, or relapse, or merge gradually into the more severe form.

In the severe type the onset of the disease may be extraordinarily rapid.
Within a few days or weeks the entire joint may be disorganised. An
atrophic and a hypertrophic type may be distinguished according to whether
the wearing away and disappearance of bone, or the extravagant new forma-
tion of bone, is the more prominent feature. Sometimes, and especially in
the knee, the clinical features are those of an enormous hydrops, with
fibrinous and other loose bodies and hypertrophied fringes, like an exaggera-
tion of that met with in arthritis deformans, only there is usually great
oedema of the periarticular tissues, the joint is wobbly or flail-like from the
stretching and destruction of the controlling ligaments, and there is no
sensation in the joint. Sometimes, and especially in the shoulder, the
wearing down and total disappearance of the ends of the bones is the
prominent feature, this being also attended with flail-like movements and
with coarse grating of the opposed surfaces. Dislocation is chiefly observed
at the hip. It is rather a gross displacement, with exaggerated mobility,
than an ordinary dislocation, for it is usually possible to draw the bones
apart. An occasional and very striking feature is the extensive formation
of new bone in the capsular ligament and surrounding muscles, resulting in
the presence of large masses and plates which may add materially to the
already existing deformity of the joint. In certain cases the enormous
swelling of the joint and its rapid development may suggest the growth of
a malignant tumour.

The most useful factor in diagnosis is the entire absence of pain, tender-
ness, and common sensibility. The freedom with which a tabetic patient
will allow his disorganised joint to be handled, moved, and the bones
grated on each other, requires to be seen to be appreciated.

In syringo-myelia (" gliomatous arthropathy ") joint affections are more
frequent (in 10 per cent of cases) than in tabes, and more often involve the

30 JOINTS, DISEASES OF

upper extremities in correspondence with the seat of the lesion in the
lower cervical and upper dorsal segments of the cord. Except that the
joint disease is rarely symmetrical it closely resembles the arthropathy of
tabes. The complete analgesia of the joint structures and of the overlying
soft parts, is well illustrated by cases in which the joint has been painlessly
excised without an ansesthetic, and by one case in which the patient himself
was in the habit of evacuating the fluid from his elbow by means of a pair
of scissors. The painless whitlows of the fingers known as "Morvan's
disease " are similarly the result of the analgesia, for the patient neglects
breaches of the skin surface which allow of the entrance of pyogenic
infection.

Suppuration, apart from superadded infection through a breach of the
surface, does not occur in any of the forms of spinal arthropathy.

Spontaneous fracture may occur as a complication, both in tabes and in
syringo-myelia.

The prognosis is uncertain as to progress, and is unfavourable as regards
treatment, for in the majority of cases it is at the most capable of retarding
or arresting the progress of the disease.

Treatment is usually directed towards supporting and protecting the
joint by means of bandages, splints, and special apparatus. In the lower
extremity the use of crutches may assist in taking the strain off the
affected limb. When there is much distension of the joint, considerable
relief may follow the evacuation of fluid. The best possible result being-
rigid ankylosis in a good position, it may be advisable to bring this about
artificially by arthrodesis or excision where only one joint is affected, and
where the cord lesion is such as will permit of the patient moving about.
Although the victims of tabes are unfavourable subjects for operative inter-
ference on account of their liability to uncontrollable vomiting or diarrhoea,
and to intercurrent complications, the wounds heal remarkably well. When
the limb is quite useless, and there is danger from superadded septic infec-
tion, if one is to interfere at all, it should be by amputation.

(3) In cerebral lesions attended with hemiplegia (from haemorrhage,
tumour, etc.) joint lesions are occasionally met with in the paralysed limbs
attended with evanescent pain, redness, and swelling. The secondary
changes in joints which are the seat of paralytic contracture are considered
elsewhere.

An intermittent neuropathic hydrops has been observed, especially in
the knee, in cases of epilepsy, hysteria, general paralysis of the insane,
etc., but it is of little clinical importance.

Y. Hysterical or Mimetic Joint Affections

Under this heading Sir Benjamin Brodie in 1822 described a rare
affection of joints, characterised by the prominence of the subjective
symptoms and the absence of any pathological changes in the joint.
Although chiefly met with in young adult single women and widows, with
impressionable nervous systems, and more often in those of good social
circumstances, it occurs occasionally in robust women, and even in men.
The onset may be referred to injury or exposure to cold, or it may be
associated with some disturbance of the emotions or of the generative
organs, or it may result from an involuntary imitation of the symptoms
of organic joint disease presented by another patient.

It is characteristic that the features develop abruptly without sufficient
cause, that they should be exaggerated and wanting in harmony with one

JOINTS, DISEASES OF 31

another, and that they do not correspond with the typical features of any
of the known forms of organic disease. In some cases the only complaint
is of severe neuralgic pains, more often these are associated with excessive
tenderness and with impairment of the functions of the joint. On examina-
tion, the joint presents a normal appearance, but the skin over it is remarkably
sensitive. The slightest touch is more likely to excite pain than deeper and
firmer pressure over those points which are usually tender in ordinary forms
of organic joint disease. Stiffness is a variable feature. In some cases it
may amount to absolute rigidity, so that no ordinary force will elicit move-
ment at the joint. It is characteristic of this, as of other neuroses, that
the symptoms come and go without apparent reason. When the patient's
attention is diverted the pain and stiffness may disappear. There is never
any actual swelling of the joint, although there may be an appearance of
this from wasting of the muscles above and below. If the joint is
kept rigid for long periods secondary contracture may occur, in the knee
with flexion, in the hip with flexion and adduction. Attempts at move-
ment may then cause cracking noises. Months or years may elapse without
any further developments.

The diagnosis is often a matter of considerable difficulty, for there are
organic lesions, e.g. a tuberculous focus in the bone close to a joint, which
may cause vague neuralgic pains for months or years before rupturing into
the articulation. Examination with the Eontgen rays, and of the joint
under chloroform, may assist in difficult cases, but there are cases on record
in which an experienced surgeon has been obliged to perform an exploratory
operation in order to make a definite diagnosis. The greatest difficulty is
met with in the knee, where the condition may closely resemble tuberculous
disease.

The treatment, besides that directed to the constitution of the patient,
chiefly consists in improving the nutrition of the affected limb by means
of massage and baths, and electricity. Splints are to be avoided. In
refractory cases considerable benefit may follow the application of Corrigan's
button or the actual cautery. Complete recovery is the rule.

VI. Tumours and Cysts

Innocent tumours of the synovial membrane, whether fatty, fibrous, or
cartilaginous, are not recognised as distinct from the overgrowth of the
corresponding tissues in certain chronic forms of joint disease, e.g. arthritis
deformans.

Sarcoma of the synovial membrane has been chiefly met with in the
knee, and has been nearly always mistaken for synovial tuberculosis. One
case is recorded in which a localised sarcoma of the synovial membrane gave
rise to the symptoms of loose body in the knee. The usual treatment has
been to cut away the synovial membrane, and so far as the recorded cases
go it has been quite successful. The spindle and round-celled sarcomata
are much more malignant than the myeloid.

Cysts of joints constitute an ill-defined group. They include ganglia
which form in relation to the capsular ligament, most commonly on the
outer aspect of the knee joint in the interval between the bones and in
front of the tendon of the biceps (see " Knee Joint, Diseases of "). Cystic
distension of the bursce which communicate with the joint is most often
met with in relation to the knee in cases of long-standing hydrops. It
has been maintained that similar cystic swellings may result from the
hernial protrusion of the synovial membrane between the stretched

32 JOINTS, DISEASES OF

fibres of the capsular ligament, and the name "Baker's cysts" has been
applied to them, after Morrant Baker who first described them.

In the majority of cases these cysts give rise to little inconvenience, and
may be left alone. If interfered with at all, they should be excised.

VII. Loose Bodies

While there is probably no more controversial subject in surgical
pathology than the origin and nature of loose bodies, their clinical aspects
and treatment are quite clear and straightforward. It is convenient to
group them anatomically into two great classes : those composed of fibrin,
and those composed of organised connective tissue.

I. Fibrinous Loose Bodies (corpora oryzoidea).

These are homogeneous or concentrically laminated masses of fibrin,
sometimes quite irregular in shape, sometimes resembling rice grains, melon
seeds, or adhesive wafers ; usually present in large numbers, they are some-
times solitary and may then attain considerable dimensions. They are not
peculiar to joints, for they are met with in tendon sheaths and bursse ; their
origin from the synovial membrane may be accepted as proved. Their presence
is almost invariably associated with chronic effusion from the synovial mem-
brane (hydrops) in tuberculosis, arthritis deformans or Charcot's disease.
"While they may result from the coagulation of fibrin-forming elements in
the exudation, their occurrence in tuberculous hydrops would appear to be the
result of coagulation necrosis or fibrinous degeneration of the surface layer
of the diseased synovial membrane. However formed, their characteristic
shape is the result of mechanical influences, and especially of the movements
of the joint. Clinically they constitute an unimportant addition to the
features of the disease with which they are associated ; they never give rise
to the classical symptoms of loose body ; their presence may be recognised,
especially in the knee, by the crepitating sensation imparted to the fingers
when the bodies are moved to and fro in the fluid. The treatment is con-
cerned with the disease underlying the hydrops ; if it is desired, however, to
empty the joint by means of a trocar and cannula, one must be prepared
for the cannula becoming blocked with the bodies ; should this occur the
alternative is to evacuate the fluid and bodies by means of a suitable
incision.

Extravasation of blood into a fringe of the synovial membrane of the
knee has been known to give rise to the symptoms of loose body ; such a
condition is quite capable of spontaneous recovery.

II. Bodies composed of organised connective tissue, e.g. fatty,
fibrous, cartilaginous, bony, or combinations of these, are met with under
the following conditions : —

A. In association ivith some general disease of the joint ; loose bodies
composed of connective tissue or of its derivatives are comparatively common
in arthritis deformans ; they are also met with in certain rare forms of
synovial tuberculosis and in Charcot's disease. They are derived almost
exclusively from hypertrophic changes in the synovial fringes ; they may
consist of fat, e.g. the arborescent lipoma ; more commonly the connective-
tissue cells of the fringes proceed to form fibrous tissue, cartilage, and bone
in varying proportions and combinations, after the manner commonly
observed in innocent new growths. Like other hypertrophies on a free
surface, they tend to become polypoidal and pedunculated, and exhibit a
limited range of movement. The pedicle or stalk may, however, give way
and the body becomes free ; in this condition it may wander about the joint,

JOINTS, DISEASES OF 33

or lie snugly in one of its recesses until disturbed by some exaggerated
movement or twist ; in the free state it is alleged to be capable of con-
tinued growth, deriving the necessary nutriment from the surrounding
fluid. The number and size of the bodies vary indefinitely; they have
been known to attain the size of the patella, and to number considerably
over a hundred. A rarer type of loose body in arthritis deformans is met
with when a portion of the " lipping " of one of the articular margins is
detached by injury. It may also be mentioned that in Charcot's disease
large loose bodies composed of bone may be formed in relation to the
capsular and other ligaments, and may be made to grate upon one another.

In this group of organised loose bodies, the disease which underlies
their formation is the predominating element in the clinical features and
in the treatment ; the characteristic symptoms of loose body (vide infra)
are often absent, when present they are to be regarded rather as a com-
plication of the existing disease than as a separate entity.

B. Loose bodies in joints which are otherwise healthy ; these constitute
the majority of cases causing the classical symptoms of loose body, and the
majority also of cases which call for operative treatment. Confining our
statements to established facts, it may be said that they are chiefly met with
in the knee and elbow of healthy males under the age of thirty. The
complaint may be of vague pains in the joint (usually ascribed to rheuma-
tism), of occasional cracking on movement, or of impairment of function,
usually an inability to extend or flex the joint completely. In many cases
a clear account is given of the characteristic symptoms which arise when
the body is impacted between the articular or other closely applied surfaces
of the joint, viz. sudden and intense pain, loss of power in the limb, and
locking of the joint, followed by effusion and other accompaniments of a
severe sprain. On some movement of the joint, the body is disengaged, the
locking disappears, and recovery takes place as after an ordinary sprain or
twist. These symptoms may continue, and the attacks of impaction may
be repeated at irregular intervals during a period of many years. On
examining the joint it may be found to contain fluid, and there may be
points of special tenderness; the patient himself, or the surgeon, may
succeed in palpating the loose body, and in making it roll beneath the
fingers, especially if it be lodged in the suprapatellar pouch in the case of
the knee, or on one or other side of the olecranon in the case of the elbow.
In most instances the patient has carefully observed his own symptoms, and
is aware, not only of the existence of the loose body, but of its situation
when " attached," or of its erratic appearance at different parts of the joint
when " free." When the body contains bone it may show in a skiagraph.
While in some cases the patient attributes his symptoms to some definite
injury (rightly or wrongly), exactly similar phenomena may occur apart
altogether from traumatic influences. The treatment consists in opening
the joint and removing the body ; the patient recovers with an absolutely
healthy joint ; if at the operation the opportunity is taken of inspecting
the articulation, it is usually found to be normal, the important point
being that there is no general disease such as attends the presence of loose
bodies in the preceding groups.

The characters of the loose bodies removed by operation, as above described,
are remarkably constant; they are usually solitary, about the size of a bean
or almond, concavo-convex in shape, the convex aspect being smooth like
an articular surface, the concave aspect more often uneven, nodulated,
suggesting the healing over by fibrous or fibro-cartilaginous tissue, of an
irregular fracture of spongy bone. Such bodies when still attached may
VOL. VI 3

34 KIDNEY, PHYSIOLOGY OF

be lodged in a kind of compartment, nest, or excavation, in one of the
articular surfaces, usually one or other condyle of the femur, from which
they may be readily, shelled out by means of an elevator. They usually
present on section a nucleus or core of spongy bone or calcined cartilage.

The origin of these loose bodies is too controversial to allow of its being
discussed in the present article ; some maintain their origin entirely from
injury, others regard them as originally derived from the synovial mem-
brane, while Konig regards them as portions of the articular surfaces which
have been detached by a morbid process which he calls " osteochondritis dis-
secans." The subject of loose bodies in joints may be concluded by mentioning
the traumatic displacement or detachment of one or other of the semilunar
cartilages in the knee, which give rise to the characteristic symptoms of
loose body, modified by the accurate localisation of the offending body and
the conditions under which it is met with.

LITERATURE.— C. Macnamara. Diseases of Bones and Joints.— Howard Marsh.
Diseases of the Joints. — Richard Barwell. Diseases of the Joints. — F. Konig. Tuberculose
der Knochen und Gelenke. — "Watson Cheyne. Tuberculous Disease of Bones and Joints. —
Fedor Krause. Die Tuberculose der Knochen und Gelenke. — Karl Schuchardt. Die
Krankheiten der Knochen und Gelenke. — Nicholas Senn. Tuberculosis of Bones and Joints.
— -Mikulicz's Conservative Treatment of Tubercular Joint Disease. — Henle and C. W. Cath-
cart. Loose Bodies in Joints. — Sir G. M. Humphry. Brit. Med. Journ. 19th Sept. 1888. —
Atlas of Illustrations of Pathology, New Syd. Soc. " Gout and Rheumatic Gout," fasc. xiii. 1900.

Kala Azar. See Malaria.
Ke I o i d . See Cicatrices.
Kidney.

1. Physiology of, page 34.

2. Surgical Affections of, page 40.

3. Morbid Affections of. See articles Nephritis, Uremia,

Urine, etc.

PHYSIOLOGY OF THE KIDNEY.

Str,ugture. — The kidney possesses two capsules : externally, a loose covering
containing a large number of fat cells embedded in loose connective tissue,
and within this a strong tunica fibrosa, composed of ordinary white and
yellow elastic fibres, which forms a close covering for the organ, turning in
at the hilum where it is continuous with the sheaths of the vessels. The
latter covering can be comparatively easily and completely peeled off.
Underneath this and lying on the surface of the kidney there is a network of
smooth muscle fibres. If a longitudinal section be made through the organ
from the outer border to the hilum, the glandular tissue can be easily recog-
nised as consisting of two parts, cortical and medullary, the former reddish
brown in colour, covering the latter and sending prolongations between the
bases of the pyramids (Bertin's columns), the latter presenting a paler striated
appearance, and arranged in the form of pyramids with the apices of the
latter towards the hilum. Each pyramid is seen to be made up of a papillary
part with indefinite striations and a boundary zone where the striae are
well marked. Each papilla projects into a short tube, the calyx ; and these,
of which there are eight to ten, unite to form two or three infundibula, and
these finally form the pelvis of the ureter. As the striations pass out
towards the bases of the pyramids they become more widely separated by
blood-vessels, and are continued outwards as the pyramids of Eerrein almost
but not quite to the surface of the cortex.

Course of the Urinary Tubules. — The convoluted tubules constitute the

KIDNEY, PHYSIOLOGY OF 35

principal part of the cortex, in most animals forming about \ to ■} of the
length of the entire urinary tube. They constitute the true secreting as
opposed to the collecting part of the glandular tissue, and arise from Bow-
man's capsule which surrounds the glomerulus. There is a short and narrow
constriction where the capsule passes into the proximal tubule, the direction
of the latter being at first towards the surface of the organ, so that, as one
may see on microscopic examination, the superficial zone is free from
glomeruli. The tube becomes very convoluted and gradually passes down-
wards towards the medulla. Some distance before the medulla is reached
the tube becomes straighter, although still maintaining a spiral course, and
when the limiting layer of the pyramid is reached it narrows down to a
thin tube which pursues a straight course, in some cases almost completely
down the papilla, usually, however, bending round either in the deeper parts
of the marginal layer or in the superficial papillary region. It then pro-
ceeds upwards parallel to the descending limb as the ascending limb of
Henle's loop. This limb widens out either at the bend or shortly before or
after the loop, attaining about double the diameter of the descending limb,
and after a more or less irregular course passes into the distal convoluted
tubule which is much shorter than the proximal one. This communicates
with a collecting tube through a short connecting branch, and the collect-
ing tubes unite to form larger ducts, papillary ducts, which open by means
of pores on the apices of the papillae.

Microscopic Structure of the Tubules, etc. — Bowman's capsule is composed
of a structureless membrana propria with an inner lining of flattened epi-
thelial cells. The membrana passes almost entirely down the urinary tube,
thinning towards the end and disappearing when the principal branches of
the papillary ducts are reached. The epithelium maintains its squamous
character as far as the neck of the tubule, becoming then higher and pre-
senting a very distinctive appearance in the convoluted tubules. The cells
lining these tubules show no definite cell outlines, but present a peculiar
granular appearance in the outer basal part where the granules are arranged
in linear fashion as rods, these being limited to this part and not passing
into the cytoplasm of the inner portion of the cell. If the tissue be well
fixed another peculiar feature of these cells may be made out, namely, a
striated cuticular hem {Burstenbesatz) about 2 to 3 /x in thickness, the strise
of which are exceedingly fine, certainly not more than -5 //, in thickness, and
are affirmed by some authors to possess vibratile movements, but this is
more than doubtful. There are no secretory capillaries, and probably no
intercellular bridges between these cells. A clearer epithelium lines the
descending limb of Henle, the cells of which are flattened and contain
nuclei which project into the lumen of the tube, giving the latter a wavy
appearance. These tubes might be confused with capillaries if it were not
for the characteristic nuclei, the thick membrana propria, and the absence of
blood corpuscles. The epithelium which lines the thick limb of Henle's looped
tubule, the spiral and the distal convoluted tubule is similar to that lining
the first part of the convoluted tube, only the epithelium is not so high, the
rods are not so long, and the lumen appears wider. As the tube passes into
the connecting and then into the collecting ducts the protoplasm of the
cells becomes much clearer, staining more faintly with eosin, while in the
papillary ducts the epithelium becomes more cylindrical and very clear.

Structure and Arrangement of the Vascular Parts. — The Malpighian bodies
consist of two parts : (1) a capsule which, with the exception of the place of
entrance and exit of the afferent and efferent vessels, completely invests a
tuft of capillaries ; (2) the glomerulus, a space being left between the cap-

36 KIDNEY, PHYSIOLOGY OF

sule and the capillaries which communicates with the lumen of the con-
voluted tubule. A small artery, vas afferens, immediately after its entrance
through the capsule breaks up into a bundle of fine capillaries, from which
the blood is removed by an efferent arteriole with non-striped muscle in its
wall, the- vas efferens, a vessel of smaller calibre than the afferent one. This
efferent vessel in its turn breaks up into capillaries which surround the con-
voluted tubules. The glomerular capillaries contain no muscle fibre, and so
far as can be made out by the silver method, show no cell outlines such as
would appear if they possessed an endothelial coat, while the afferent and
efferent vessels and the capillaries around the convoluted tubules undoubt-
edly possess one. The walls of the glomerular capillaries seem to consist of
a protoplasmic mass containing no definite cells, while covering the glomeru-
lus and passing into the hollows on the tuft there is what Kolliker terms
a syncytium, containing numerous nuclei, but, showing no distinct cell out-
lines, in this respect differing markedly from the covering of the embryonic
glomeruli. The glomeruli vary in size, and some have distinguished a large
from a small variety. Where the vessels penetrate the capsule there is
direct continuity between the latter and the syncytium, or, in the case of
embryonic Malpighian bodies, the cylindrical cells covering the glomerulus.
It is not necessary in this short article to describe the development of the
kidney, but it is advisable to refer shortly to the two important views that
are at present held by scientists on the mode of development of the glandu-
lar part, and it is perhaps best to refer to it in this place after the glomeru-
lar structure has been discussed. The most widely -held theory is that
associated with the names of Toldt, Kolliker, and Golgi, who supported the
view that all the renal tubules are developed as outgrowths from the ureter,
which pass out as solid cones of cells, forming ampullae which divide into
two coiled branches under the capsule or close to the interlobular septa.
These columns of cells become hollowed out, and capillaries, developing
locally or penetrating as branches of the renal artery, go to form the
glomerulus in the lower curve of the ampulla branches which run an
S-shaped course. The other view, and one which is gradually becoming more
widely accepted, is that the collecting tubules are derived from ureter out-
growths, but that the Malpighian bodies, the convoluted tubules, and Henle's
loop are developed from a solid clump of mesoblastic cells at the periphery
of a lobule lying in close relationship to the termination of the dilated ex-
tremity of a collecting tube. This mass of cell becomes hollowed out and
coiled in the form of an S, its lower limb going to form a Malpighian
body, the glomerular capillaries developing in situ, the rest of the coiled
S-tube going to form convoluted tubules, Henle's loop — part of the junc-
tional tubule probably. The junction of the collecting with the convoluted
tubule takes place at the periphery of a lobule. This view, brought forward by
Thayssen, is supported by the work of Bornhaupt, Hamburger, and Herring.
The afferent vessels of the glomeruli are derived from interlobular
arteries which pass out through the cortex after arising from the renal
arterial arches which radiate out between the cortex and medulla. The'
interlobular arteries also send branches to the capsule, and from their lower
part near their origin from the arch a few straight branches to the medulla —
arteriolce rectce verce. The efferent arterioles from glomeruli lying close to
the Malpighian pyramids divide up to a slight degree, and form false straight
vessels in the medulla — arteriolce rectce spurice. The true straight vessels
arise not only in the way above mentioned, but also in part from the con-
cavity of the arches and from adjacent afferent glomerular arterioles. The
veins arise from the capillary sources which have been described, and the

KIDNEY, PHYSIOLOGY OF 37

blood is returned by the venous arches to the renal vein, no valves being
present in their course. It is important to remember that the renal cap-
sules have a blood-supply from many sources, e.g. the renal artery before its
entrance into the hiluin, suprarenal, and lumbar branches and interlobular
arteries, and that the veins communicate with those of the neighbouring
organs, and partly also with the portal system (Turners and Lejars).

Lymphatics. — Between the blood-vessels and the convoluted tubules there
are freely anastomosing lymph spaces, while in the medulla and the medullary
rays they are poorly represented. The capsules have a rich lymph-supply.

Nerves are derived from the coeliac plexus of the sympathetic, and
accompany the vessels at their entrance, some fibres forming a close net-
work around the blood-vessels. The modes of termination of these nerves
have been the subject of much discussion. Vaso-motor fibres have been
traced to the adventitia, and muscular coats of vessels and other fibres to
Bowman's capsule, but a connection with the convoluted tubules has not
yet been made out with certainty.

The connective tissue is sparse in amount, being richest relatively in the
pyramids, especially in the papillary zone.

Mechanism of Eenal Secretion. — A fairly complete account has been
given of the structure of the normal kidney, because it is impossible to
speak about the probable functions of an organ without an exact knowledge
of its structure. Of course one must avoid drawing conclusions as to
function from structural arrangements alone as experimental ; pathological
and clinical evidence must all be brought to bear on the subject. Still,
and this is especially true of the kidney, the very strongest proofs as to the
functions of an organ are often derived from a careful preliminary study of
its structural relationships. The observer is struck by the marvellous
arrangement and character of the blood-vessels and urinary tubules, leading
one immediately to surmise that the vascular arangements in and around
the glomerulus must play an important part in the mechanism of renal
secretion. The afferent vessel breaks up into a number of fine divisions
which offer a large surface for filtration, while the narrowness of the efferent
arteriole and the introduction of another set of capillaries all offer high
resistance to the blood-flow, so that the blood flowing through the glomerular
capillaries must be under comparatively high pressure. Again, the fact
that the urinary tubule is directly continuous with the space between
Bowman's capsule and the tuft of capillaries is strong proof that the
channel is one for collecting material that has been obtained from the
capillary blood, the pressure in the circulating blood being considerable,
while that in the secreting tubules, if there be no hindrance to outflow of
urine, is inappreciable. The purely mechanical explanation that Ludwig
gave of urinary secretion is supported by many well-established data.
Ludwig's theory is that a very dilute urine, containing all the constituents,
filters through the glomerular capillaries under the influence of blood-
pressure, and that the urine subsequently becomes more concentrated on
its downward course through the convoluted tubules by diffusion of water
from urine to blood. If this view were correct, then every rise or fall in
pressure in the glomerular capillaries ought to be succeeded by a corre-
sponding increase or decrease in the amount of urine, and in many cases
this is true. If the local blood-pressure fall, as, for example, after stimula-
tion of the renal nerves or mechanical obstruction to the flow of blood
through the renal artery, the amount of water secreted becomes correspond-
ingly diminished, while a rise in local pressure, such as would result from
section of the renal nerves, especially if after this the spinal cord or the

38 KIDNEY, PHYSIOLOGY OF

splanchnics be stimulated, or if large blood-vessels elsewhere be ligatured, is
followed by an increased flow of urine. There are certain facts, however,
which make it difficult to accept this view in its entirety, and one is that
any obstruction to venous outflow diminishes the amount secreted. This in
itself is no argument against the process being one of filtration, because in
such an organ as the kidney venous congestion results in arterial anaemia ;
but if in such a case of venous congestion with diminished excretion,
nitrates of the alkalies be transfused through the blood, then immediately
there is a great increase in the flow of urine. Such diuretics may act even
when secretion has stopped, and the results cannot be explained satis-
factorily by action on a peripheral vaso-motor mechanism. An hydrseruic
plethora is very short-lived after injection of these substances, the composi-
tion of the blood remaining very constant. The action of caffein as a
diuretic has been carefully investigated with the oncograph, and it has
been shown that secretion varies directly with the shrinkage or expansion
of the kidney. It is difficult, on the filtration hypothesis, to explain why
two crystalloids like urea and glucose, although their percentages in the
blood are approximately the same, should pass into the urine in such
different proportions. Again, as Max Hermann pointed out, if the renal
artery be occluded for 1| minutes only, the secretion of urine will not begin
again until three-quarters of an hour have elapsed. It must be remembered
also that the water has not only to pass through the capillary walls, but
also through the glomerular covering, be that epithelial or syncytial, and
that must offer a great resistance to filtration (cjp. Leber's experiments on
Descemet's membrane in the cornea).

There can be no doubt that venous congestion may cause obstruction to
urinary outflow, either directly, or as a result of oedema by compression of
the collecting tubules in the medullary rays as Ludwig pointed out, and
also that hindrance to urinary excretion may cause venous congestion.

But if there are difficulties in the case of a physical explanation of the
glomerular functions, they are but insignificant in importance compared to
those which immediately present themselves when an attempt is made to
prove the accuracy of the second part of Ludwig's hypothesis, namely, the
concentration of the dilute urine in the convoluted tubules. Long ago
Hoppe-Seyler pointed out that water passed from blood serum to urine
across an animal membrane, and more recently it has been shown that-
normally the osmotic pressure of the urine is decidedly greater than that of
defibrinated blood or serum. These experiments proved that Ludwig's
theory in its original form was untenable, for in order that the process of
concentration might be carried on, work must be performed by the cells of
the convoluted tubules, that is to say, the process must be regarded as one
of active secretion. Yon Sobieranski adopted Ludwig's views in the main,
but regarded the cells of the convoluted tubules as actively absorbing water.
His conclusions were based upon certain experiments dealing with the course
of coloured substances through the kidney after injection. He noticed
that pigment granules tended to be deposited in the part of the cell next
the lumen, and not in the basal part, as one would expect, if the cells of the
convoluted tubules took them up from the blood. Munk and Senator hold
with the first part of Ludwig's theory, but accept Heidenhain's view of the
specific secreting properties of the cells of the convoluted tubules and
ascending limb of Henle's loop.

The Specific Secretory Hypothesis was put forward by Bowman in
the first place, but he based it largely on his interpretation of the arrange-
ment of glomeruli, tubules, and blood-vessels, rather than on any experi-

KIDNEY, PHYSIOLOGY OF 39

mental evidence. It is to Heidenhain that we are indebted for most of the
experimental proofs that render the theory a feasible one. As a result of
experiments carried out by himself and others, for the purely physical
hypothesis he was led to substitute one in which the specific activity of
gland cells played the important role. In his classical article on renal
secretion in Hermann's Handbuch he sums up his views under five brief
headings : —

1. As in all other glands, secretion in the kidneys depends upon the
active participation of special secretory cells.

2. In the first place, the cells covering the glomerulus secrete water and
the salts which as a rule accompany it, e.g. common salt.

3. The other set of cells, lining the convoluted tubules and the broad
part of the ascending limb of Henle's loop, serves for the secretion of the
special urinary solids, urea, uric acid, etc., and also a certain quantity of water.

4. The degree of activity of the two types of cells depends upon

(a) Percentage of water and urinary solids in the blood.

(b) Eapidity of blood-flow in renal capillaries so far as that affects food-
supply for the special cells.

5. The great variability in the composition of the urine is explained by
variations in the secretory activity of the two types of cells.

Thus, according to Heidenhain, the water of the urine is most largely
obtained from the glomerular capillaries, and he only differs from Ludwig in
emphasising the importance of the rate of blood-flow rather than altera-
tions in the pressure. Nussbaum's experiments on exclusion of the glom-
eruli of the amphibian kidney by tying the renal artery and studying
the effects before and after injection of urea, sugar, egg, albumin, and
peptone, are not conclusive, because it has been shown that it is impossible
to cut off the glomerular blood-supply by tying the renal artery, seeing that
there are anastomoses between branches of the renal portal (which was sup-
posed to supply the convoluted tubules alone) and the renal artery.

It is also unnecessary to describe fully Heidenhain's experiments on the
injection of indigo-carmine, because the results that he obtained have been
shown to be by no means so definite as was at first imagined. Even if it
were proved beyond doubt that indigo-carmine was secreted by the rodded
cells of the convoluted tubules and the broad part of the ascending limbs
of Henle's loop, and that the glomerular secretion merely washed it down
into the collecting tubules, it by no means follows that urea, uric acid, etc.,
pursue the same course. It is unfortunate that urea, owing to its great
solubility, is so quickly excreted that its detection in the tubules is
impossible, and uric acid also is excreted without, as a rule, leaving any trace
of its passage through the rodded cells. Kecently, however, crystals of uric
acid have been detected in those cells by Minkowski after adenin has been
given. They are often found in the lumen of the convoluted tubules, never
in Bowman's capsule. Hsemoglobin seems without doubt to pass through
the glomeruli (Adami), and in all probability serum albumin also.

Kibbert and Bradford's experiments on the effects of removal of larger
or smaller portions of the kidney substance may be interpreted in so many
ways that their discussion in this article is unnecessary. Although most of
the important work on renal secretion was done by older investigators,
recent workers have been able, thanks to the ingenious invention of Roy, by
means of the oncograph, to register alterations in the volume of the kidney.
This instrument is simply a plethysmograph of a suitable shape for the
kidney, with oil as the medium, and a recording piston with attached lever
for recording changes in the volume of the organ.

KIDNEY, SUKGICAL AFFECTIONS OF

Influence of the Nervous System. — Eeference has already been made to
the influence exerted by the vase-motor nerves, the fibres of which leave
the cord by the anterior roots of the 11th, 12th, and 13th dorsal nerves
(Bradford). According to Bradford, vaso- dilator fibres accompany the
constrictors, as stimulation of the above-mentioned anterior roots by
induction shocks at the rate of one per second produces active dilatation of
the vessels without a sufficient rise in blood-pressure to explain the enlarge-
ment of the kidney. Stimulation of the posterior roots produces refiexly a
similar dilatation. There has always, however, been doubt expressed as to the
existence of special secretory nerves to the kidney, although Eckhard showed
that polyuria might be produced by mechanical stimulation of that portion
of the superior vermes of the cerebellum adjacent to the medulla if the
hepatic nerves had been previously cut, or if the stimulation were a superficial
one. He could not obtain the results which C. Bernard did on puncture of the
floor of the 4th ventricle. It is hardly necessary, however, to accept the
view of special secretory nerves for thej kidney, as the existence of vaso-
dilator fibres which can be stimulated either directly or refiexly explains
the results obtained by Eckhard, and also the polyuria that occurs in
hysteria, epilepsy, etc. The histological work of Berkeley on the nerve-
endings in the kidney requires further confirmation.

The subject of physiological albuminuria is a difficult one. It is
perhaps most easily explained on Heidenhain's hypothesis, the permeability
or secretory activity of the cells being affected by any cause which tends to
produce slowing of the local circulation, and as a result disturbance of the
intracellular metabolism from want of oxygen, etc. (See article " Urine.")

It is impossible at present to speak with any certainty about the internal
secretion of the kidney, although a vast amount of work has been done by
French and Italian scientists on this subject.

Specific Renal Functions. — Although in this article special reference has
been made to the kidney as an organ of excretion, at the most selecting from
the plasma preformed urinary constituents, it is necessary also to bear in
mind that it possesses the power of altering plasma constituents, and in some
cases even carrying out important syntheses. Thus the alkaline phosphates
of the plasma appear in the urine as acid ones, and in at least some animals
{e.g. the dog) the synthesis of benzoic acid and glycocoll to form hippuric
acid takes place in its tissues. Although some at present hold that the
kidney is the seat of uric acid formation, the proofs that have been brought
forward in support of the view do not warrant one in coming to that con-
clusion, and the same holds with regard to the renal origin of urea.

LITERATURE.— Structure: Kolliker's Handbuch der Gewebelehre, Bd. iii. H. i. 1899.
Functions: Article by Heidenhain — " Harnabsonderung " in Hermann's Handbuch der Phy-
siologie, Bd. v. 1881. — Article l>y Starling in Schafer's Text-book of Physiology, vol. i. 1898.

SURGICAL AFFECTIONS OF THE KIDNEY.

Movable and Floating .
Injuries of

Traumatic Nephritis Hi
Perinephritis and Peri-
nephritic Abscess
Eenal Fistula .
Pyelitis ....
Suppurative Pyelonephritis
Cysts ....

Stone in the Kidney
Eenal Tuberculosis .

Hydatid Cysts ....

Hydronephrosis

. 47

Pyonephrosis ....

Tumours of . .

. 48

Actinomycosis ....

The Ureter ....

. 53

Injury ....

Inflammation and Dilatation

. 57

Stone .....

. 58

Operative Procedures

KIDNEY, SUEGTCAL AFFECTIONS OF 41

Movable and Floating Kidney

Movable kidney differs from floating kidney in its relation to the
peritoneum ; the latter possesses a complete peritoneal covering and pedicle,
while the former is retroperitoneal. The distinction is purely anatomical,
and has no importance except in so far as it may increase the difficulties of
the operator. The range of movement may be quite as great in a movable
as in a floating kidney, and the symptoms do not differ.

Kiister believes that 2-5 per cent of the population, irrespective of
sex or age, have movable kidneys ; and Albarran states that in 10 to 12
per cent of women there is a slight degree of renal mobility.

(1) The Surroundings. — The kidney may move inside its fatty capsule,
or the capsule may be loose and wander with the kidney (Morris). The
amount of fat surrounding a movable kidney is not necessarily diminished
even when the rest of the body is emaciated (Eosenstein).

(2) The Range of Movement. — This may be very slight or extensive, and
is clinically described in three degrees (Glenarcl).

First degree. — The kidney descends partly below the ribs on deep
respiration, but its upper pole remains hidden. These slighter cases form
the majority of movable kidneys (Morris).

Second degree. — The kidney descends entirely below the ribs, and the
fingers may be pushed above it.

Third degree. — The kidney wanders over an extensive area of the
abdomen. It is anchored by its pedicle of vessels, but may swing as low
as the iliac fossa or across the median line of the body.

Sometimes a tilting movement takes place, by which the convex border
turns forwards. The movement may be in the " plane of the loins," and
has been termed " cinder-sifting," but this movement cannot be detected
by palpation (Morris).

The mal-placed kidney may form adhesions in some new position and
there become fixed.

(3) The State of the Kidney. — Often it is quite normal. A slight degree
of pelvis dilatation is frequent, even hydronephrotic changes may take
place from kinking of the ureter. Infection of the dilated or congested
kidney may produce pyonephrosis or pyelonephritis. Calculus may com-
plicate a movable kidney, but it is uncommon.

(4) The Condition of other Abdominal Organs. — Frequently there is no
abnormality, sometimes a general enteroptosis is present (Glenard).
Movable liver occurs pretty frequently with movable kidney, more rarely
the spleen is mobile.

(5) Some Accidents which may occur. — Torsion of the renal pedicle,
causing acute symptoms of renal pain, collapse, vomiting, and even anuria,
may occur and be repeated. This usually happens after some exertion, and
only occurs when the degree of mobility is very pronounced. Intermittent
hydronephrosis is very frequent. The symptoms resemble those of
strangulation, but in addition there is the presence of a renal tumour
which disappears with the relief of the symptoms, and is followed by a
marked temporary polyuria. Sometimes the hydronephrosis is permanent.
Intermittent jaundice is said to occasionally complicate movable kidney
on the right side, probably from pressure or dragging on the bile duct.
This often passes off suddenly and after a few days reappears (Litten).

Etiology . — The kidney is normally more movable in women than in
men, and' the preponderance of the former over the latter in movable
kidney is striking — 6 or 8 times more frequent in females (Eollet).

42 KIDNEY, SUKGICAL AFFECTIONS OF

The right side is much more often affected than the left (9 to 10 per
cent, Fiirbringer) ; though both sides are sometimes affected (7'2 per cent).
Most' cases occur between the ages of 20 and 40, but it also occurs in
children. An hereditary tendency has been traced in some cases.

The most frequent exciting causes are. injury, and those changes which
are induced by weak, pendulous abdominal walls, the result of repeated
pregnancies, or distension by ascitic fluid or abdominal tumours. Eapid
emaciation, enlargement of the kidney, and tight-lacing are said to be
factors in the etiology.

Symptomatology. — Pain. — The most constant and usually the most
striking indication of wandering kidney is pain (96 per cent). It will
therefore be considered somewhat in detail. The suffering caused by a
movable kidney shows great variation in its intensity and character.
Every kidney which can be detected by palpation and classed as movable
does not cause pain ; many, indeed, are symptomless, and this especially
applies to the left side ; but in the majority of instances pain is present in
some degree. Often it is the only prominent symptom the patient
complains of (43*3 per cent), at other times it is accompanied by general
conditions of neurasthenia, or hysteria, J)T by disturbance of digestion ; in
other cases the genito-urinary system bears the brunt of the disorders (31
per cent).

In some cases pain amounts only to a dull, heavy aching in the loin, or
a sense of dragging, which is continually present ; in others there is
occasional pain, often severe and situated in the lumbar region. Some-
times it is described as sharp, and may radiate to the abdomen and even to
the thigh.

Exercise has a marked effect in starting and increasing the pain, while
rest often relieves it.

In women, and they form the majority of patients, the menstrual periods
are attended by more severe exacerbations of the pain, necessitating rest
in bed.

In another class the pain is paroxysmal in character and agonising in
severity, and shows the same radiation as renal colic. Some strain or
extra fatigue often starts these attacks, and after a variable duration they
suddenly cease.

Temporary disappearance of the symptoms of a movable kidney some-
times occurs, very rarely the improvement is permanent.

The collection of symptoms which represent a movable kidney are of
the most varied description. Simple enumeration only leads to further
confusion, for none of them are characteristic. They fall, however, into
three well-marked groups, and are thus most conveniently described
although combinations of the different types occur : — (1) Genito-urinary
group, (2) Gastro-intestinal group, (3) Nervous group.

(1) Genito-urinary Group. — These cases resemble renal calculus in
many of its phases.

The pain is in the loin or side ; it is often insidious in its onset, and of a
dull, heavy, aching character. It may be occasional and increased by
exercise (horse-riding, etc.), or it may be constant and become more severe
as time goes on.

In a large number of cases (41*8 per cent) there are attacks at intervals
of severe pain exactly simulating renal colic in their character and dis-
tribution. The same intense agony and prostration are seen, the same
nausea and vomiting, sweating, feeble rapid pulse, diminution of urine, and
even anuria and uraemia (Pribram) may be present, and the same sudden

KIDNEY, SUEGICAL AFFECTIONS OF 43

relief from the symptoms is obtained. The patient during an attack sits
doubled up with his knees to his chin and his body bent (Newman). The
temperature often rises during an attack (Fiirbringer). Hsematuria may
follow these attacks. Blood was present in the urine in 18 per cent of
Morris's cases of movable kidney.

During an attack the kidney is increased in size, and relief is followed
by a copious polyuria.

Frequency of micturition may occur (18 per cent), and pus in small
amount may be observed.

Albumin is present in the urine in 14 per cent of cases (Schilling).

So closely do these cases resemble renal calculus that in many the
exclusion is only complete when the renal substance has been incised and
the kidney and pelvis explored by the finger.

(2) G astro -intestinal Group. — The symptoms point to gastric trouble,
the patient is dyspeptic, complains of pain in the back, a sensation of
sinking and weight after food. Constipation is often present, nausea and
anorexia are frequently complained of. Jaundice may occur as already
noted.

On examination of the abdomen the stomach is sometimes found dilated
(Litten says in 55 per cent), and sometimes a general condition of
enteroptosis may be discovered.

(3) Nervous Group. — The symptoms vary greatly. The patient is often
nervous, irritable, excitable, and suffers from palpitation. Severe neuralgia
may be present, or the pains may be vague and variable. Spots of hyper-
esthesia and anaesthetic areas often occur. Sometimes weakness of the
lower extremities has been seen (Senator).

The symptoms may be typical of hysteria, or the patient may be
neurasthenic. In those cases there is often a neurotic family history, and
a slight injury frequently determines the onset of the symptoms.

Diagnosis. — In all cases the diagnosis rests upon the discovery of a
movable tumour which is recognised as the kidney.

Sometimes a movable abdominal swelling is the first sign noted. It
may be discovered by the patient either before or after the onset of
symptoms. In the slighter degrees of movable kidney, if the mobility
can be detected the position of the swelling leaves no doubt as to its nature,
but in the more pronounced cases, where the range of mobility extends
towards or into the false pelvis or towards the middle line, there are other
conditions which may lead to confusion.

The movable kidney has certain characters which should always be
looked for. The shape can sometimes be made out and is characteristic ;.
there are no sharp borders ; by manipulation the organ can be replaced in
the loin ; on percussion a dull tympanitic note is obtained anteriorly.

No conclusions can be drawn from the percussion of the loin, or the
presence or absence of hollowing in that region. Albarran points out that
sometimes, when the right lobe of the liver is displaced downwards and the
kidney movable, the size of the kidney may appear very great on palpa-
tion, and a hydronephrotic tumour be diagnosed when none is present.

The abdominal swellings most likely to be confused with a wandering
kidney are : — .

(1) An Ovarian Cyst with a long Pedicle. — The swelling can be reduced
into the pelvis, but cannot be placed in the renal region. It is dull on
percussion, and sometimes the abdominal wall is sufficiently thin to
recognise that the form is not that of the kidney.

(2) A distended gall-bladder has a smaller range of mobility, and its

44 KIDNEY, SUEGICAL AFFECTIONS OF

dulness is continuous with that of the liver, while it is not reducible into
the lumbar fossa. Jaundice, if present, inclines to the diagnosis of dis-
tension of the gall-bladder, but it should not be forgotten that an attack of
jaundice may complicate a movable kidney, and further, that biliary and
renal colic may be very similar, and, lastly, that the two conditions may
occur together.

(3) An hydatid cyst attached to the lower surface of the liver may
cause difficulty. It is, however, painless and swings round an axis
corresponding more to that of the gall-bladder than the kidney. The
tumour is not reducible into the loin.

(4) A wandering spleen has a sharp margin, sometimes notched, and a
dull percussion note. A movable spleen may sometimes descend as low as
the iliac fossa.

(5) Mesenteric tumours are median in position, and show a greater
transverse than vertical mobility, and are dull on percussion.

Treatment. — (1) In some cases a floating kidney is discovered by the
patient or medical attendant, but no symptoms which might arise from it
are present. Here it is better to advise the patient to wear an abdominal
belt, for symptoms may arise at a later date. Sometimes the knowledge of
possessing a movable kidney seems to excite uneasiness and discomfort, and
eventually hypochondriasis.

(2) In cases where symptoms are present a snugly fitting abdominal
belt with an elastic cushion, with an air pad on its inner surface, and
placed low down on the affected side, should always be tried, and in thin
patients a fattening diet will sometimes be found of advantage.

Where the symptoms are controlled by the apparatus the patient will
have the option of retaining it for life or having an operation performed.
"Where the symptoms are unaffected by wearing an abdominal belt,
operation should be recommended. It will usually be welcomed by the
patient as an almost certain means of escape from her sufferings.

The operation of nephrorraphy or nephropexy is, in the hands of an
experienced surgeon, practically without a mortality (1 to 2 per cent). In
the majority of instances the cure is complete and permanent. For
technique, see Operations.

The success of the operation may be considered in relation to the
various symptoms.

Pain disappears in 88 per cent of cases after nephrorraphy (Albarran).

In the gastro-intestinal group the troubles are less often completely
relieved.

It is in the nervous type that treatment either by bandage or by
operation has least effect. In Albarran's statistics only a small number
were cured by nephrorraphy (14 per cent were improved, 36 per cent
showed no improvement in their nervous symptoms). This author considers
that if the cause be allowed to remain the condition will be aggravated, and
he does not hesitate to recommend operation even in those nervous cases
after orthopaedic measures have failed.

(3) In cases where enteroptosis is present an abdominal belt should be
worn, and no operation is called for unless some complication such as
hydronephrosis arises.

LITERATURE. — Kuster. Die chir. Krankh. der Nieren. 1896. — Albarran. Maladies
du rein. — Morris. Surg. Dis. of Kidney. 1885. — Rosenstein. Path. u. Therap. der
Nierenkrankh. 1894. — Glenard. Diagnostic du rein mobile. 1896. — Watson. Journ. of
Cutan. and G.-U. Dis. 1897, p. 315. — Morris. Hunterian Lectures, 1898. — Albarran.
Assoc, franc, de chir. 1898. — FUrbringer. Diseases of the Kidneys and Urinary Organs.

KIDNEY, SUEGICAL AFFECTIONS OF 45

Trans. Gilbert, 1895. — Senator. Dcr Krankheiten dcr Nicren. 1896. — Rosenthal.
T/ierapeut. Monatschr. 1896. — Pkihram. Wicn. Med. Pressc. 1881. — Newman. Led. on
Sun/. Dis. of Kid. 1888.

Kidney, Injuries of

Injuries to so essential and so vascular an organ as the kidney cannot
fail to be of grave moment. Even a slight contusion in one so predisposed
may start a tuberculous affection, or induce chronic interstitial nephritis ;
whilst the severer lacerations, involving, as they frequently do, the super-
jacent peritoneum or surrounding abdominal viscera, result in heavy
mortality.

The practical consideration of the subject falls into two divisions.

(a) Subcutaneous lesions.

(b) Open lesions.

(a) Subcutaneous lesions of the kidney are more commonly met with in
civil practice. They occur chiefly in men. The nature of the violence may
be direct or indirect ; its effects may be limited to the organ (simple lesion),
or extend to the encasing structures or the surrounding viscera (complicated).
Thus the peritoneum covering the anterior surface may be split, or the
adjoining ribs may be broken (5-5 per cent, Kiister) and their fractured
ends buried in the kidney ; or the liver, spleen, gut, even the diaphragm
and lung, may be coincidently and extensively torn.

Pathological. — There may be mere subcapsular ecchymoses or laceration,
or the capsule may be ruptured and deep multiple stellate fissures traversing
the kidney substance even to the hilus may exist, or the kidney may be
rent into two or more isolated pieces or reduced to a pulp. The fatty
capsule and muscles are frequently torn, and in children up to the age of
ten the peritoneum is very liable to be split open, because the prenephric
subperitoneal fat is absent before that age (Poireault).

The mortality rises from 304 to 80 per cent when the peritoneum is
torn (Edel).

Clinical Notes. — (i.) Anatomical limits of the haemorrhage.

If the renal capsule is ruptured the blood issues into the perirenal
tissues until it is checked by the fatty capsule ; a firmish rounded tumour
is thus formed. But if the fatty capsule is also torn, the haemorrhage, if
severe, escapes along the cellular planes in every direction, and may reach
the other side of the vertebral column, or extend to the thigh, groin, or
scrotum. In exceptional adult cases, and in children under the age of ten,
the blood may pour into the peritoneal cavity through a split in the
peritoneum. If a deep calyx or the pelvis be opened, urine follows' in the
track of the blood.

In the severer cases every element favouring virulent septicity is
thrown in combination. An organ, whose role is to eliminate micro-
organisms and toxins, is damaged ; adjacent to it is the colon harbouring
myriads of pyogenic bacilli, and around it is a widespread undrained bog
of fluid blood, clot, damaged tissues, and putrescible urine. Small wonder
that the mortality is great (30 per cent simple, 70 per cent complicated),
and that it is largely due to septicity.

(ii.) The indication of renal hematuria consequent upon slight indirect
violence.

It is important to remember that pre-existing disease of the kidney
may cause that organ to be easily lacerated. I always suspect the previous
health of a kidney which bleeds on slight indirect violence, such as a short

46 KIDNEY, SUKGICAL AFFECTIONS OF

fall upon the buttocks, or a muscular strain in lifting. Severe renal
haemorrhage upon the occurrence of slight violence after mid-adult age and
in old people should raise a suspicion of malignant growth : in the decade
between thirty and forty of calculus, and in the young adult of chronic
interstitial nephritis or tubercle. I have met and verified several instances
of each of these diseases, the first intimation of which was given by the
appearance of hsematuria consequent upon a slight fall, blow, or strain.

Symptoms. — Some amount of shock is present in nearly every case of
renal laceration, the collapse being the more profound and lasting in pro-
portion to the severity of the lesion. As the shock passes off, nausea and
vomiting set in, severe pain is experienced in the area of the injured kidney
and along its ureter, the kidney becomes exquisitely sensitive, and the
muscles over it markedly rigid. Tympany ensues in a few hours although
the peritoneum may be uninjured. Blood is passed in the urine; the
patient is often tormented with dysuria, although the actual quantity of
urine may be markedly diminished, and a swelling is soon detectable in
the renal region, whilst ecchymosis, more or less extensive, discolours the
skin, and marks the subcutaneous limits of the effused blood.

Hematuria. — This cardinal symptom varies according to the site and
extent of the laceration, although it is no indication of the amount of the
blood escaping, for much of it may percolate from the kidney into the peri-
renal area. If the laceration is purely cortical the hsematurial admixture
may be only microscopical and in the shape of a few blood cylinders. If,
however, the kidney is extensively torn, the bleeding may be so profuse as
to pour down the ureter, enter and fill the bladder, and either clot there,
producing retention, or frequently issue thence by the act of urination,
arterial in hue and fluid in consistence. It may even cause death. Thus
Grawitz has collected seventeen cases in which death ensued within half an
hour to fifteen hours after the injury. Usually, however, although the
haemorrhage is at first bright, it rapidly darkens and clears off by the third
day. If it remains profuse after the fourth day there is cause for alarm,
especially if the swelling in the loin continues to increase. Sometimes it
is intermittent, or varying in amount at different times, or it may even be
absent (Newman). In forty-nine deaths from uncomplicated lesions of the
kidney fifteen died rapidly without hematuria (Tuffier).

Course of a severe Case. — When the peritoneum has been torn and the
adjoining viscera have been lacerated the patient usually succumbs. Kiister
says that only one case — that of Kehr — in which the peritoneal covering
was proved to be torn has recovered ; but in the more favourable cases,
when the injury is limited to the kidney, the patient, when he has escaped
the immediate danger of hsemorrhage, is confronted with that of septicity
(76 per cent, Tuffier). This usually takes the form of cystopyelitis, which
quickly induces in its turn pyelonephritis, perinephritis, and finally septic
peritonitis. It is needless to add, if the inflammatory products around the
kidney are unrelieved by free drainage the patient dies.

Septicity is usually heralded by a rigor, rise of temperature, and in-
crease of lumbar pain, and often these symptoms follow hard upon the
introduction of a catheter ; for there is no doubt that part at least of the
heavy mortality is due to septic catheterism.

(b) Open Lesions of the Kidney.

The symptoms which attend open wounds of the kidney are the same
as those which mark subcutaneous lesions, but with these differences: —
Hsematuria, which is the cardinal symptom, is nearly always present ; the
pain, which is in proportion to the laceration of the muscles, is usually

KIDNEY, SUEGICAL AFFECTIONS OF 47

more localised, and does not extend along the ureter ; whilst, owing to the
generally free escape of blood or urine, the lumbar swelling is not present,
or does not become so marked a feature. The prolapse of the kidney into
the wound is probably rare. The danger of haemorrhage is as great as in
subcutaneous wounds, but that of septicity is less, owing to the escape from
the wound of the products of inflammation. Hence the death-rate is lower
(15 per cent). Moreover, statistics show that many of the patients have
been operated upon, and nearly always successfully.

Treatment. — (a) In subcutaneous lesions.

In a fair proportion of those cases in which the hematuria, the renal
pain, and the loin swelling are slight, rest in bed will suffice. The applica-
tion of an ice-bag for a few hours relieves mentally, if it does not influence
the pain and haemorrhage. Small doses of an opiate are always beneficial,
but internal haemostatics by injection or by the mouth are useless. Subse-
quently strapping the affected side as if for fractured ribs (Morris) affords
comfort and rest.

In graver cases, when the hematuria is severe and the loin swelling is
marked, operative interference becomes a necessity, not only to arrest the
haemorrhage, but also to give a free outlet to the perirenal collection of
blood and, may be, urine, and to anticipate and prevent those septic changes
which prove so fatal.

In fact, early surgical intervention will become, I believe, the rule in
all the severer cases. Whether tamponade of the surface of the
kidney and subsequent free drainage, or stitching of the fissures, or partial
or complete nephrectomy, should be undertaken are questions which must
rest upon the judgment and experience of the operator. At the same
time that the loin is opened, the necessity or the advantage of perineal
drainage of the bladder should be raised. If the bladder is feeble or
atonic, and clots show a decided tendency to form in that viscus, it is
good surgery to place a large perineal drain in the bladder so as to
prevent the inevitable cystitis and those ascending changes which follow
in its train.

If prolonged shock and symptoms of profuse haemorrhage into the
peritoneum point to the tearing of the peritoneal surface of the kidney, the
abdomen must be opened by the transperitoneal incision and the blood
removed.

(b) Open lesions.

In all cases of open lesion it is essential, if the haemorrhage or hsema-
turia be severe, to enlarge the wound, and to deal with the kidney as the
injury demands.

LITERATURE. — Kuster. Die chirurgischen Krankhciten der Nieren. 1896. — Edel,
quoted by Guterbock. — E. Grawitz. "Ueber Nieren verletzungen," Archiv f. klin. Chir,
1888-9,38. — Newman. Renal Cases. 1899. — Albarran. Maladies du rein. — Simon. Chir.
der Nieren, ii. Theil, 1876.— Morris. Surgical Diseases of the Kidney. 1885. — Tuffiek.
"Traumatismes du rein," Archiv. gin. de med. ii. pp. 591-697; 1888. — Dumesnil, quoted
by Tuffier. — Guterbock. Die chir. Krankh. der Harnorgane. 1898. — Poireault. "De la
contusion du rein," These de Paris, 1882.

Traumatic Nephritis

After a blow or injury to the loin the onset of nephritis is marked by a
rigor and the temperature rises. Blood is usually present in the urine, and
when this disappears after a few days the microscope will show tube-casts
and epithelium, and for a day or two red granular material is often observed
(Kuster). Albumin is present in varying amount.

48 KIDNEY, SUKGICAL AFFECTIONS OF

A peculiarity of traumatic nephritis is the combination of albuminuria
with polyuria, which contrasts with the scanty urine of acute nephritis. A
further distinctive feature is the rapid development of oedema of the feet,
face, or sometimes the whole body. The oedema is not uncommonly (three
in five cases, Potain) confined to one side, the injured one, of the body
(Kiister). Some days later pyuria may appear, and if the temperature
remains high suppuration has probably occurred.

It should not be forgotten in the diagnosis of traumatic nephritis that
old-standing renal disease may have preceded the injury.

Prognosis. — In traumatic nephritis only one kidney is affected, and re-
covery as a rule takes place, the attack passing off in ten or fourteen days
(Morris). Some cases go on to chronic nephritis (Albarran). Suppuration
sometimes occurs and will require surgical interference.

Treatment.— The rest and diet already observed on account of the injury
should be continued. Leeches may be applied to the loin.

LITERATURE. — Kuster. Die chir. Krankh. der Nieren. — Potain. Gaz. des h6p. fev.
1883. — Morris. Surgical Diseases of the Kidney. — Albarran. Maladies du rein.

Perinephritis and Perinephritic Abscess

Inflammation of the areolar tissue around the kidney is comparatively
rare, the published cases not exceeding more than a " few hundred "
(Ftirbringer).

Etiology and Pathology. — The inflammation may stop short of actual pus
formation and form only a dense fibrous thickening, or suppuration may take
place.

Before describing the symptoms of the disease it is convenient to review
briefly those conditions which may lead up to it, and which one may expect to
find in the history of a case, and also to note some facts of interest in their
bearing on the prognosis.

The disease is more frequent in males than in females, and occurs usually
betweeri the ages of 20 and 40.

The right side is more often affected than the left ; it is seldom bilateral
(3 in 230 cases, Kuster).

In many cases careful examination of the other organs and attention to
the history reveal no condition likely to induce suppuration, but in others
the history of a chill, a muscular strain or a blow in the lumbar region
(probably 26 per cent, Duffin) is obtainable, or some small suppurating
point, such as a whitlow, a boil, or carbuncle, is present ; in 17 per cent
(Fen wick) perinephritic abscesses occurred during the course of some severe
toxemic condition, such as pyamiia, small-pox, scarlatina, etc. ; a few can be
traced to disease in the appendix, liver, pelvic organs (23*5 per cent) or the
vertebrse (3-7 per cent).

Lastly, a separate group of cases takes origin in disease of the kidney
(32 per cent), and these are named " secondary " while the others are
" primary."

Symptoms. — In some conditions the causative disease is severe, and masks
the symptoms of the perirenal suppuration, which may only be discovered on
the post-mortem table. Thus pelvic cellulitis may be complicated by peri-
nephritic abscess without the latter condition sufficiently modifying the
symptoms already present to attract attention, or during the malignant
course of pyaemia or small-pox the kidney may become surrounded with pus
without the latter giving any indication of its presence. In the primary class
of cases the disease attains its most rapid and pronounced form ; even here,

KIDNEY, SUEGICAL AFFECTIONS OF 49

however, the signs may sometimes be obscure and lead the practitioner astray,
and this occurs more especially in the older and more weakly individuals
than in the more robust.

In the other type of case where some renal disease is present and especi-
ally of calculous nature, the symptoms are more moderate, the course more
prolonged, and the patient less likely to survive the disease.

Onset. — In most cases the disease commences insidiously with pain
(64 per cent, Fen wick) of a dull, heavy character in one loin, or an indefinite
aching on both sides, which later becomes more localised. This mode of
onset is especially frequent when the abscess is secondary to renal disease,
less often when other causes are present.

When the suppuration arises apart from disease of the kidney a sudden
rigor and rise of temperature is more likely to be the preface to further
symptoms.

In a few cases (9 per cent) symptoms of urinary disease are already
present when other signs appear.

Pain. — The initial pain soon becomes more severe. From a dull, heavy
aching it becomes sharper and more stabbing, and often assumes a par-
oxysmal character of great severity. Sometimes it is intermittent, and it has
at times a remarkable " tertian " character (Elias). Confined at first to the
affected loin it later radiates along the distribution of the lumbar nerves to
the hip, thigh, knee, groin, and sometimes to the testes and penis.

The pain is exaggerated by every movement, and especially by coughing
or straining. Tenderness in the renal region is an early and invariable
symptom. Some temporary anaesthesia or paresis of the thigh on the affected
side has been observed (4 per cent, Nieden).

Fever may be severe, commencing at the outset of the disease with
rigors. It is usually continuous with morning remissions. Like the pain
it may be absent at intervals, and in this may resemble ague. Fever is a
more striking feature in those cases which arise apart from renal disease than
in those where the inflammation spreads from the kidney. It has been noted
that in some cases the pain and fever become less marked a day or two
before the appearance of the swelling. In subacute or chronic cases the
fever may be slight.

Tumour. — In the early stage nothing but marked tenderness is dis-
covered on palpating the loin. So severe is this pain on pressure that the
abdominal wall resents the palpating hand by firm contraction, and an
anaesthetic is advisable in making the examination. With the patient
recumbent, if one hand be placed so as to support each loin, an increased
sensation of weight may be detected by the surgeon before any swelling can
be defined (Morris). After some days (eight to fifteen days, Trousseau) or
weeks or even months, an indefinite fulness can be felt deeply placed, and
later a lumbar tumour appears (87 per cent, Fen wick).

At first this is firm and ill defined, later an actual lumbar swelling can
be seen. The natural curve of the waist becomes obliterated, the skin
cedeniatous, and the surface temperature is raised. Sometimes when the
abscess tends to point the skin is reddened and congested.

On palpation the swelling is very tender, and if the abdominal wall
permits, the outline will be found indefinite and fluctuation can be elicited.
The respiratory movements do not affect the tumour. The flank is dull, but
at the anterior and inner side of the swelling a tympanitic note betrays the
position of the colon. Much depends for ease in examination on the thick-
ness of the abdominal wall. As much as six pints of pus have been
concealed beneath a fat belly wall without fluctuation being discovered
VOL. vi 4

50 KIDNEY, SUEGICAL AFFECTIONS OF

(Morris). There is a distinguishing tendency to bulge backwards into the
flank, rather than forwards into the abdomen (Rosenstein).

In some subacute cases a tumour is found lying under the unaltered
skin, which is very elastic, often resistent and globular or egg-shaped, rarely
of hour-glass form (Giiterbock).

Effect on the Attitude and Movements of the Patient. — Lameness is often
observed as an early symptom (Duffin), and the patient in sitting tends to
rest on one tuber ischii (Morris). The body is often held bent forwards and
inclined towards the affected side. This habit will draw attention to the
hip, and in the presence of referred pain in this region without marked
lumbar symptoms may lead the observer astray.

On examination the patient lies on his back in bed, with the thigh of the
diseased side flexed, and often abducted and rotated outwards, so that the
heel is in relation to the dorsum of the other foot, the thigh cannot be
extended without pain, and adduction is performed with difficulty (G-ibney).
The condition closely resembles that of the second stage of hip-joint disease,
and is due to the unconscious attempt at relaxation of the abdominal and
psoas muscles. There is, however, entire absence of tenderness, swelling, or
muscular wasting about the hip joint, and by flexion of the thigh the psoas
muscle is thrown out of action, and rotation is now perfect and painless.

Condition of the Urine. — Changes in the urine occur in 33"3 per cent of
cases (Giiterbock), but these give very little aid to diagnosis.

In cases of old-standing urinary disease there may be blood, pus, etc., in
the urine, but the condition is unaffected by the presence of perinephritic
suppuration.

When renal disease is absent, albumin, casts, and even blood may appear
in the urine, probably from pressure on the renal vein (Morris). Pus is
present at intervals in 10 per cent of primary cases (Fen wick). In some
cases a large number of bacilli have been discovered in an almost normal
urine preceding rupture into the renal pelvis (Fiirbringer). Often no
urinary trouble is present at all, or only the abundant lithatic deposit of
febrile urine.

General Symptoms. — Constipation is invariable, and is a marked feature
of the case, while flatulence is very troublesome.

Doubtless the constipation may be partly explained by the great increase
of pain when the bowels are moved.

The appetite fails, there is often nausea, sometimes vomiting, and in acute
cases rapid loss of flesh occurs.

Interference with movements of the diaphragm causes- a marked frequency
of respiration.

Unilateral oedema of the foot or leg is sometimes observed, and has pre-
ceded the other symptoms by some weeks.

Diagnosis. — Apart from the latent cases there are two broad types, the
acute and the chronic.

The practitioner is most likely to be led astray only during the early
stage before the swelling appears, and only pain and fever are present. In
cases where fever and rigors are the prominent feature of the case, some acute
infectious disease, such as influenza, scarlatina, or typhoid is simulated.

In the history there may be little to guide one, but a strain or lumbar
injury should always lead to examination of the kidney region. The pain in
the back in these fevers is more general, and there is no tendency to unilateral
localisation as in perirenal inflammation. In a few days the appearance of
a rash or other signs will clear up any doubt.

In cases of less febrile type the continuous aching or shooting pain may

KIDNEY, SUEGICAL AFFECTIONS OF 51

resemble lumbago, neuralgia, and even renal colic. In lumbago the pain
shows some relation to movement, it is bilateral, the muscles are tender on
pinching them up, and fever is wanting.

In neuralgia there is absence of the marked tenderness of perirenal
abscess, no temperature or rigors, and the pain is more completely inter-
mittent.

Renal colic is accompanied by marked urinary changes, blood, pus, and
frequent micturition, and these are reliable guides, because the onset and
course of the symptoms in the form of peri-renal abscess which complicates
renal calculous disease, and which is accompanied by changes in the urine,
are usually insidious and moderate (Fenwick). At a later stage, when a
swelling has become evident, the condition most likely to be mistaken for
perinephritis is pyonephrosis.

Pyonephrosis. — Here, however, the course is more chronic and the
symptoms less severe, pain is not a marked feature of the disease, tenderness
is less marked, the tumour is well denned and regular, and the skin of the
post-renal area lacks that waxy, oedematous condition so frequently observed
in perinephritis.

Appendicitis may closely simulate perirenal abscess, and may be a cause
of it. The tenderness is, however, usually at a lower level and the swelling
is in the iliac fossa. .

In less acute cases a cold abscess, originating in spinal caries, may
resemble perinephritic abscess. The angular curve, the rigidity of the whole
spine, the local tenderness on jarring the column or on pressing the spinous
processes, and the slower course and smaller size of the abscess, will lead to
a diagnosis.

Treatment. — Before diagnosis is certain, the treatment (rest, diet,
medicine) is that of any acute fever. In early cases where perirenal
inflammation is suspected, cupping, fomentations, and opium may aid in
bringing about a resolution, for it is undoubted that a few cases do not go
on to pus formation, but much time should not be wasted on these measures,
and as soon as perinephritis is diagnosed, incision and evacuation of the
abscess is the safest and most speedy means of treatment. It is well to
bear in mind the following points in recommending operation : —

1. In acute cases septicaemia and pyaemia may occur.

2. In less acute the abscess may burrow and rupture in various directions.
Eupture occurs on an average in from three to five months (Lancereaux),
and has a death-rate of 53 per cent (Eosenberger).

3. The majority of unoperated cases do not rupture, but die of exhaustion
from hectic and waxy disease (Newman).

4. "Primary" cases are more favourable, mortality 16 percent (Kiister),
than " secondary " (to kidney disease), mortality 49 per cent (Kiister).

5. And lastly, when free incision is employed 94*4 per cent recover,
irrespective of primary or secondary disease, while without operation only
13-6 per cent survive (Poland).

LITERATURE. — Furbringer. Diseases of the Kidneys and Urinary Organs. 1898. —
Fenwick, Dr. S. Obscure Diseases of the Abdomen. 1889. — Kuster, quoted by Albarran. —
Duffin. Med. Times and Gazette. 1872.— Fischer. Volkmann's Klin. Vortrage, No. 253,
1885.— Elias. Dent. med. JVochenschr. 1879. — Albarran. Malad. chir. du rein.- — Morris.
Surgical Diseases of the Kidney. 1885. — Trousseau. Clinique med. de V Hotel Dieu. Paris,
1898, tome iii. — Guterbock. Die Chir. Kranlch. der Nieren. 1898. — Gibney. Chicago
Med. Joum. and Exam. 1880. Quoted by Morris. — Newman. Surgical Diseases of the Kidney.
1888. — Rosenberger. Die abscedirende Paranephritis.. Wtirtzburg, 1878.

52 KIDNEY, SUEGICAL AFFECTIONS OF

Kenal Fistula

Etiology and Anatomy. — After wounds of the kidney urine may be
discharged for some time, but the fistula is of short duration. If the
calices or pelvis of the kidney be opened, and especially if suppuration be
superadded, the discharge is more likely to be prolonged. Most renal
fistulee either follow operations upon the kidney or occur spontaneously.

1. Fistula folloiuing Operation. — The fistula is usually tortuous and lined
with granulation tissue which projects at its orifice. Phosphatic deposit
may take place on the walls, and urea and urinary salts are present in the
discharge. After a time the urine may disappear from the discharge from
destruction of the remaining kidney tissue.

Obstinate Symptoms. — The general health is often quite unaffected so
long as the discharge is free, and after lasting for many months or years
(sometimes seven years, Morris) the fistula sometimes closes, and the wound
becomes sound and permanently healed. In other cases the discharge
diminishes, but at the same time the improvement in the general health
apparent after the original operation is not maintained, there is continuous
pain in the renal region, tenderness on pressure, and a swelling is still felt
there. The temperature is raised, and now and again a sudden rise and
fall occurs and the strength fails. In other cases the fistula closes
completely, the temperature suddenly rises, and there is pain and tender-
ness in the renal region. Sometimes the attack is accompanied by a rigor,
and vomiting may occur. In a few days the skin becomes reddened and
tender, the scar breaks down and the discharge recommences, but from
time to time these attacks of retention recur. Septicemia or pyaemia
supervene in some cases where the drainage is incomplete.

2. Spontaneous fistulaz are not often met with, since early operation has
been recognised as the best treatment for kidney calculus.

The rupture of a calculous, less frequently of a tuberculous pyo-
nephrosis or a perirenal abscess, most often occurs in the loin, and usually
at the triangle of Petit (Albarran). The opening may, however, be in the
loin or buttock, or some part of the abdominal wall distant from the seat of
the disease. The opening is commonly single, and although secondary
openings do occur, they are not so often observed as in urinary fistuke
originating in the lower urinary tract (Guterbock). Sometimes the
orifice is situated in an intercostal space. In these cases, fortunately, the
pleural sac is pushed up and is not involved (Morris). Eupture into
abdominal viscera (stomach, intestines, etc.), and even a fistula communi-
cating with the lung may be formed.

Diagnosis. — Spontaneous fistula opening at some distant point may cause
difficulty, but the discharge of urine and the history of urinary disease and
abnormality in the urine will betray its origin.

Treatment. — Fistuke following operation should be kept clean, and the
surrounding skin protected by an ointment. If phosphatic encrustation of
the track has taken place, it should be syringed with an acid solution (weak
hydrochloric acid).

When the discharge is slight a sufficient pad should be worn to absorb
it, even a copious discharge of urine in the loin may be compatible with
comfort if a receptacle be worn (Morris). Exuberant granulations should
be touched with silver nitrate, and a small superficial sinus may sometimes
close after a few applications of the hot wire, but there are some conditions
which demand operative interference. These consist in —

KIDNEY, SUEGICAL AFFECTIONS OF 53

(1) Recurring attacks of retention of the discharge, complete or incom-
plete.

(2) The inconvenience of the discharge becoming intolerable.

(3) Nephrotomy for tubercular or calculous pyonephrosis is a temporary
measure to tide the patient over a crisis ; when the health has improved
sufficiently nephrectomy will probably be required to avoid a permanent
fistula and the effects of prolonged suppuration.

Pyelitis

The relation between the kidney and its pelvis is so intimate that in-
flammation of the latter seldom occurs without the kidney participating to
some extent in the process. It is practical, however, to draw a distinction
between pyelitis and pyelonephritis, for in the latter the disease has invaded
the kidney structure and the prognosis is grave.

Etiology. — Any period of life may be affected, but pyelitis is most fre-
quent during middle life and in males, for the causes which produce it come
into operation at that time and in men.

There are three classes : —

(1) Those arising from local conditions, of which stone in the pelvis is
the most important (pyelitis calculosa).

(2) Those following disease of the lower urinary organs. These, which
form the largest class of pyelitis, may be briefly enumerated : —

Cystitis with decomposition of the urine and ascending inflammation of
the ureter and pelvis, in which the process travels from the bladder to the
renal pelvis or kidney by direct continuity along the mucous membrane, or
by way of the lymphatic vessels (Lindsay Steven).

Gonorrheal cystitis accounts for 18 per cent of cases of pyelitis (Finger),
but vesical calculus, bladder growths, etc., are predisposing causes, and septic
catheterisation a frequent exciting cause.

Atony of the bladder from obstruction or paralysis and decomposition
of retained urine is a frequent cause, and in fact 74 per cent of those who
die with hypertrophy of the prostate suffer from pyelitis, and in fatal cases
of urethral stricture, inflammation of the renal pelvis is found in 41 per cent
(Fiirbringer).

Atony of the bladder with cystitis in spinal or cerebral disease form a
small class.

Lastly, operations in the neighbourhood of the bladder by spread of
inflammation along the ureter induce pyelitis.

(3) Infection by way of the blood stream. Pyelitis sometimes occurs
during the course of one of the acute infective diseases, such as scarlatina,
diphtheria, dysentery, cholera, typhus, small-pox, or puerperal fever.

Again, poisons introduced into the body — such as cantharides, turpen-
tine, balsams, etc. — may give rise to pyelitis during their excretion.

Tubercular pyelitis requires separate consideration, v. Eenal tubercle.

Pathology. — Pyelitis is more frequently unilateral than bilateral. This
applies especially to calculous pyelitis : in the ascending form it is often
bilateral, but one side is usually affected before the other (Fen wick) and to a
much greater extent than the other (Senator). The acuteness of the process
varies with the cause. Slight forms are catarrhal, with hyperemia and
thickening of the mucous membrane and desquamation of the epithelium,
and are found especially in early calculus. Severe infective forms may be
attended with formation of a membrane (croupous and diphtheritic), while
the chronic forms due to long presence of calculi, etc., show a thickened,

54 KIDNEY, SUBGICAL AFFECTIONS OF

discoloured, grayish mucous membrane and an infiltrated wall. Small cysts
may form with colloid contents (pyelitis cystica, Litten, v. Kalden), or small
grayish lymph follicles (pyelitis granulosa, Chiari), and ulceration is often
present.

Backward pressure is often coincident with pyelitis, and dilatation of the
renal pelvis and atrophy of the kidney substance results (hydronephrosis
and pyonephrosis). Suppurative nephritis or chronic interstitial nephritis
may occur from spread of the inflammation.

Symptomatology. — The amount of suffering depends more on the cause
than on the pyelitis itself. The severe microbic types, e.g. pygemia, etc., may
be unattended by pain, or at most have a dull aching, while in slight cases
due to calculus the agony may be intense and prolonged. Sometimes, how-
ever, pain in a pure case of pyelitis (for instance, puerperal fever), may
resemble renal colic in its intensity and distribution (Ebstein). Ascending
pain along the ureters, followed by dull aching in the kidney, may be due
to pyelitis apart from the symptoms of its cause.

The pus in the urine intermits, being usually noticed to be more abun-
dant in the first urination on rising in the morning.

General Symptoms. — Continued fever does not always accompany
chronic suppurative pyelitis unless the ureter becomes blocked, but a slight
rise of temperature may occur at night (Newman).

In uncomplicated pyelitis the most important signs are found in the
urine.

Changes m the Ukine. — Pus. — The urine, when passed, is milky and
opalescent, but on standing the pus soon separates into a creamy layer at
the bottom of the urine glass, clearly marked off from the supernatant
urine. The amount of mucus present is slight and not sufficient to cloud
the urine.

Reaction is acid; even when the urine of pyelitis is foetid it may
retain its acid reaction from admixture of the secretion of the normal
kidney. In the later stages it sometimes becomes markedly alkaline.

Odour. — In the earlier stages there is no smell. When decomposition
is pronounced Dickinson remarked a peculiar smell like sulphuretted
hydrogen, which he distinguishes from the ammoniacal odour of the urine
of bladder inflammation.

Albumin is present, but corresponds to the amount of pus. When
the deposit on boiling is excessive, it raises the suspicion that the renal tissue
has been invaded, and other signs of this complication should be looked for.

Cells. — Besides pus corpuscles numerous epithelial cells are often present,
elongated, pointed, and often overlapping each other, which a skilled micro-
scopist can detect as pelvic.

Bacteria. — Numerous micrococci and bacilli can be seen (quite apart
from decomposition) in the recently passed urine.

Diagnosis. — Pyelitis must be distinguished from — (1) Cystitis. — In cases
of pyelitis, when the urine is decomposed and alkaline, and painful and
frequent micturition is present, cystitis will be simulated, and yet the
bladder be free from disease. The history is important, for it may show
long-continued renal symptoms previous to the onset of bladder trouble ;
the amount of mucus and the ammoniacal decomposition are greater in
bladder affections. The cystoscope is the best guide in doubtful cases.
The diagnosis resting on the pyuric efflux, the shape of the ureteric orifice,
and the urine obtained from each pelvis by the ureter catheter.

In the class due to ascending inflammation from disease of the lower
genito-urinary tract the diagnosis of pyelitis apart from renal changes is

KIDNEY, SUKGICAL AFFECTIONS OF 55

very difficult, often impossible. Ascending ureteric pain followed by dull,
heavy aching and tenderness of the kidney should raise the suspicion of
this complication. It may be possible, by massage of the kidney, to obtain
an appreciable increase of the pus in the urine.

(2) Pyelonephritis and Chronic Interstitial Nephritis. — In acute pyelo-
nephritis there are rigors, high fever with a feeble, rapid pulse, a coated, dry
tongue, thirst, and vomiting. The urine is diminished in amount, and
contains a large quantity of pus and albumin. The patient rapidly sinks
into a typhoid condition.

If chronic indurative changes have occurred in the kidney there is pro-
gressive loss of weight, failing appetite, headache, thirst, and sometimes
vomiting ; the tongue is coated and the mouth dry. There is polyuria, the
urine is of low specific gravity, the albuminuria is in excess of the pus
present, and tube casts may be found. The condition of the urine is often
masked by the cystitis already present.

Treatment. — Prophylactic. — Many cases of ascending infection may be
avoided by careful antiseptic catheterisation, and the prior administration
before interference of hexamethylentetramine, gr. v.

The indications to be followed are : (1) to remove the cause ; (2) to con-
trol the amount of pus and relieve pain.

(1) This includes the treatment of renal calculus, enlarged prostate,
urethral stricture, and other conditions. A word of warning is necessary in
cases where backward pressure is an element. If there is any reason to
suspect that the renal tissue has been invaded operative interference should
be limited to the methods which throw least strain on the weakened kidneys.

(2) In all cases medical treatment should be adopted and urinary anti-
septics exhibited.

Hexamethylentetramine (gr. v), sandal wood oil, ammonium benzoate,
boric acid, natural salicylic acid, and salicylates give the best results. Sandal
wood oil is efficacious in the chronic types, or antiseptics may be combined
with the liquid extract of white sandal wood.

Tonics should be prescribed, and of these quinine and nitro-hydrochloric
acid are valuable.

In acute cases the patient should be strictly confined to bed, and dry
cupping or leeches applied locally, and opium fomentations to relieve pain.

LITERATURE. — Furbringer. Diseases of the Kidneys. 1898. — Lindsay Steven.
Glasgoiv Med. Journal, 1884. — ■ Senator. Die Erkrankungen der Nieren. 1896. — Litten.
Virchow's Archiv, lxvi. 1876. — v. Kalden. Ziegler's Beitr. z. path. Anat. xvi. 1897.
— Chiari. Prag. med. Wochensch. 1888.

Suppurative Pyelonephritis

Suppuration in the renal pelvis and kidney is the result of secondary
infection from the lower urinary tract. It is the closing stage of many
cases of old-standing cystitis, and occurs especially when some form of
obstruction is present.

Etiology. — Infection introduced into the bladder — often by a dirty
catheter — spreads to the kidneys already damaged by obstruction. This
occurs in cases of old-standing urethral obstruction (44 per cent), stricture,
enlarged prostate, etc., in long-continued cystitis (28 per cent), from calculus,
growths, etc., or in cases of bladder atony (24 per cent), from brain or spinal
disease or injury (Dickinson).

Pathology. — The septic process spreads along the ureter or its lymphatics

56 KIDNEY, SUEGICAL AFFECTIONS OE

to the renal pelvis and kidney. Yellow streaks are found passing from the
pyramids along the tubules to the cortex, where yellowish splashes or actual
abscesses are dotted here and there.

Symptoms. — There is a combination of septic absorption with uraemia.
At the outset there is a rigor, which is sometimes severe, and it may be
repeated, but often this only occurs a day or two before death.

The temperature rises to 101°-103° E., or even higher, and remains
up with slight morning remissions. Sometimes in old people, or those
advanced in cachexia, there is no fever, although other grave symptoms are
present, while in other cases the temperature may return to normal for
four or five days, and then another rise occurs. The patient complains of
thirst and headache ; he refuses food, -the bowels are constipated, and there
is troublesome flatulence. The mouth is dry, the tongue coated, brown, and
cracked (" parrot tongue "), and only protruded with difficulty. Sweating
often occurs and is profuse, but shows no relation to the rise and fall of the
temperature. There is rapid emaciation, the face has an anxious, sallow
look, but is never jaundiced. The fever is unaccompanied by excitement or
delirium. The patient becomes indifferent to his surroundings and dull.
He replies to questions but slowly, and from time to time dozes off into a
restless sleep from which he awakes with a start. Quiet muttering delirium
often occurs, the torpor increases, and an hour or two before death coma
supervenes.

Urine. — If the urine is clear before the onset, it becomes turbid and
deposits pus on standing ; often, however, it is already thick, muddy, and
alkaline from long-continued cystitis. Albumin is constantly present in
moderate quantity, and tube casts and epithelial cells are found, but these
signs are usually masked by the purulent urine of cystitis.

Diminution in the quantity of urine is constant and the specific gravity
is low. There is usually little or no pain, but indefinite aching with tender-
ness on pressure is sometimes present.

The kidney cannot, as a rule, be felt, although it is enlarged.

There are three conditions which resemble the clinical picture of a sup-
purative nephritis : —

(a) Acute nephritis (Blight's disease).

Here the urine is greatly reduced in quantity (four or five ounces in
twenty-four hours); it is smoky or porter-coloured from blood, and the
specific gravity is high (1025). The puffiness of the eyelids and dropsy, the
dry skin, and the frequent occurrence of ursemic convulsions distinguish this
disease.

(b) Pycemia is distinguished by its high swinging temperature, repeated
rigors with sweating, the secondary abscesses, and the hay-like odour of
the breath.

. Prognosis. — The condition is one of extreme gravity, and is usually fatal
within a few weeks (average 2-3 weeks, Morris). Occasionally, however,
under treatment the drowsiness disappears, the appetite improves, and the
temperature returns to normal.

In some cases of enlarged prostate with abundant residual urine, the
infection of the bladder rapidly spreads to the damaged kidneys, and within
a few days the patient succumbs, but in most cases the condition is of a
more chronic type.

The age of the patient, the previous condition of the kidneys, and the
cause of the obstruction (malignant tumours) are important factors in de-
ciding a fatal result.

KIDNEY, SUEGICAL AFFECTIONS OF 57

A dry coated tongue with increasing feebleness and drowsiness are very
unfavourable symptoms.

Treatment. — Attention to antisepsis in the treatment of stricture, pro-
static enlargement, etc., and the early removal of urethral obstruction by
operation, have reduced the frequency of this disease.

When infection has occurred no operation is availing or advisable.

The diet should consist mainly of milk, the kidneys should be flushed
with Contrexville water, distilled or barley water, and urinary antiseptics
should be administered. Dry cupping of the loins may be useful. In more
chronic cases the bladder should be washed out with boric acid, quinine, or
other antiseptic solution.

Cysts of the Kidney

Conglomerate Cysts or Cystic Metamorphosis. — The condition is a very
rare one, only a few cases have been diagnosed during life (Lindegger).
Occurring in the adult it is probably of congenital or inflammatory (New-
man) origin, and is almost invariably bilateral. There are usually some
symptoms of renal disease.

In one class of case the symptoms have resembled those of chronic
interstitial nephritis with polyuria, albuminuria, oedema, and circulatory
changes, and sometimes symptoms of urgemia occur.

In another class pain, slight or severe, sometimes resembling renal colic,
has drawn attention to the condition.

The discovery of a renal tumour is the only sign which may lead to a
diagnosis, and this appears in only 29 per cent of the cases (Lejars). In
fifteen out of twenty- two cases collected by Newman a wrong diagnosis
was made before operation.

The swelling is almost invariably bilateral (unilateral, one in sixty,
Lejars), and this differentiates it from hydatid and simple cysts which it
may resemble. Primary malignant tumour of the kidney may be suspected,
but in this the tumour is unilateral, and there are no signs of chronic
nephritis, while the pain and hematuria of a malignant tumour of corre-
sponding size are much more marked. Pyo- and hydro-nephrosis may be
excluded by the history, the absence of fluctuation, and repeated examina-
tion of the urine.

The condition may last from fifteen (Lejars) to twenty (Senator) years.
From its almost constant bilateral distribution treatment by operation is
possible only in exceptional cases. The kidney will probably have been
explored for severe pain under the impression that a movable kidney or a
hydronephrosis is present, and it lies with the surgeon to decide the question
of removal.

Large serous cysts are usually single, sometimes several are found. A
fluctuating tumour is formed, having the character of a renal swelling,
sometimes of large size. I have seen and operated on large cysts from both
head and tail of the kidney, the evident result of obstruction to some calyx
by inflammatory changes induced by stone in the pelvis or ureter. One
cyst contained a large amount of crystals of cholesterine. It is diagnosed
from an ovarian cyst by its renal characters. From hydronephrosis it is
sometimes very difficult to distinguish.

Incision and drainage is the best routine treatment, but the expert will
probably prefer to resect and stitch over the pared walls.

LITERATURE.— Conglomerate Cysts : Lindegger. These de Paris. 1896. (Albarran).
— Lejars. "Du gros rein polycystique del'adulte," These de Paris, 1888. — Senator. Die

58 KIDNEY, SUEGICAL AFFECTIONS OF

Erlcrankungen der Nieren. 1896. — Newman. Renal Cases. 1899. — Still. Trans. Path.
Soc. Lond. 1898, xlix. pp. 155-165.

Stone in the Kidney

Renal concretions usually form in the pelvis or the calyces of the kidney
from deposition of certain solid constituents of the urine. Occasionally,
however, a stone may be found in an isolated cavity in the parenchyma, the
result of obstruction to the straight tubes, and of accumulations behind
them.

There are three groups of renal stone : the acid (uratic and oxalate of
lime stone), the alkaline (lime phosphate), and the bacterial (ammonio-
magnesic phosphate). The uric acid is said to be the most usual (80 per
cent, Furbringer).

Clinical notes on —

(a) The Size. — Stones vary in size from that of a fig-seed to a dendritic
mass moulded to the pelvis and weighing about two ounces. The heaviest
recorded is one by Potel, of five pounds in weight. There is no fixed relation
between the size of the stone and the duration of the symptoms, if only the
urine remains acid and sterile. Pure oxalate of lime stones grow slower
than the uratic group. It has taken five, even ten years to produce an oxalate
stone the size of the crown of a molar. If the urine contain pus and
micro-organisms the size of the stone is roughly commensurate with the
duration of that alteration in the urine ; for phosphatic material is quickly
deposited under these conditions on any material acting as a nucleus.

(&) The Surface. — Much depends on the surface. Uratic stones are
smooth, lime oxalate stones are often covered with minute or large clear
crystals of a brownish hue. The smooth, polished uratic variety are most
usually multiple, and once in the grasp of the ureter, they pass more
readily, and give comparatively less suffering. The latter are more irregular
in shape and take longer in transit, induce greater agony, and if unvoid-
able are often single.

The chief clinical feature of the crystalline surfaced stones is the
tendency they exhibit to become buried; this is, of course, due to their
acicular surface being forced by reflex spasm into the swollen mucous mem-
brane. The favourite burial-ground is near the outlet of the renal pelvis ; but
adhesion (partial burial) is common in any part of the pelvis from the same
mechanical reasons. When fairly in the ureter they may pouch the tube
at its commencement or termination, and quietly increase in size without
much obstruction to the passage of urine.

Phosphatic stones shift the least of any ; they evince a dangerous
tendency to grow into and block the pelvic orifice of the ureter.

(c) The Site. — The early pathological changes induced by the stone
mainly depend on whether it leaves the pelvic orifice free or not.

1. Free Outlet. — An oxalate may remain buried for years near the pelvic
orifice, and yet leave the outlet free, inducing merely a thickening of the
pelvic wall and an increase in and a condensation of the fat around it ; or
a stone of the acid group may be fixed in a deep calyx for years, the outlet
remaining free, and the only change induced being an induration of the
kidney tissue due to chronic interstitial nephritis. This is at first localised
to the neighbourhood of the irritating body. In course of time most stones
evoke inflammatory resentment in the mucous membrane, and pyelitis,
pyelonephritis, perinephritis ensue. Eighty per cent of the patients who
die from renal calculus do so in consequence of suppuration (Dickinson).

KIDNEY, SUKGICAL AFFECTIONS OF 59

2. Obstructed Outlet. — Should, however, the stone be so buried near the
orifice, or so situated as to abut upon or periodically to obstruct the outlet
of the pelvis and the due egress of the secretion, serious back pressure
changes will inevitably result, e.g. dilatation of pelvis (hydronephrosis) and
atrophy of gland; and if septicity be grafted on these conditions, the
destruction of inflammation is severe and serious.

(d) The Remissions, Intermissions, and latent Periods of Stone-pain. —
To the discredit of the original diagnosis, but to the relief of the patient,
the pain of renal stone — like all other diseases of the urinary mucous
membrane — is subject to extraordinary remissions. The pain may be
absent or hardly noticeable for weeks, months, even years, and this without
apparent cause ; nay more, the suffering may end entirely.

I have seen patients free for eight, twelve, or fifteen years from any
symptom of a stone which had originally caused intolerable suffering ; and
at the end of these periods pain has recurred and become so violent as to
necessitate operation.

The theory is that the stone becomes fixed by adhesions in a hollowed-
out calyx, or fixed by branches, or that the kidney may become inactive and
even shrivel. It is to be remembered that an inert kidney which is void
of all secreting power may still preserve its size and outline, may still
be painful or become the seat of pain, may still be liable to inflammatory
attacks, and may still pour pus down the ureter into the bladder.

(e) The Pathological Changes in the opposite Kidney. — It is highly probable
that these depend greatly on the character of the calculus. When it is
an oxalate of lime calculus the opposite kidney, as a general rule, does
not form stone for many years — often not at all. In fact, the excess of
depositable oxalate appears to find the easiest exit by the affected kidney,
and a readier nidus in the original stone. In the uratic group the same
rule holds, but only in a lesser degree. It is not uncommon to find first
one kidney and then the other produce and expel a small uric acid stone.
"When, however, one has formed and become imprisoned, the surplus of
uratic material is attracted for some time to that as a nucleus, and the
opposite kidney remains free for years. In course of years the opposite
gland commences and continues to form uratic stone, so that the operator
must be prepared to deal with stone and its consequences in both kidneys
when there has been a prolonged history of uric acid urine with symptoms
of unilateral renal stone. Fifty per cent, of renal stones are bilateral.

In my opinion the real danger appears after the onset of those suppura-
tive changes which the original calculus excites. The healthy opposite
kidney is habitually irritated and gradually deteriorated by the stress
thrown upon it of eliminating special renal toxins derived by absorption
from the suppurating foci of its diseased fellow-gland. In addition to this
the healthy kidney is liable to ascending inflammatory changes from a
bladder distressed by a constant flow of pyelitic urine. A decrease _ of
functional activity and increased sensitiveness to shock or reflex inhibition
is in either case gradually acquired, and this constitutes the greatest
element of danger to the patient when colics are suffered from — cf . calculous
anuria, or when nephrolithotomy is performed. The theory of "reflex
nephritis " (Simon), which is accepted to account for these changes is, in my
opinion, untenable as well as unnecessary.

Etiology. — Injudicious diet (e.g. rhubarb and " hard " water in limestone
districts, tending to form lime oxalates), sedentary habits, mental exhaustion,
exposure to cold, inherited tendency to gravel, are all powerful factors in
the deposition of calculous material.

60 KIDNEY, SUKGICAL AFFECTIONS OF

Symptomatology. — There is one symptom — that of pain — which should
be considered in detail before the classical symptoms of the complaint are
alluded to, for it often affords the medical attendant a valuable clue to
prognosis and even treatment.

Pain. — There are two main positions and forms of pain : —
The unilateral renal pain, and ureteric spasm (renal colic). They may
be observed separately or co-exist.

A. The Unilateral Renal Pain Group. — The maximum of pain is in the
kidney region; the area can be covered by the patient's hand, the pain
being both behind and in front — more behind. It may vary from an
occasional dull ache, the outcome of mere congestion or irritation of a
crystal-charged urine to that intermittent agony which is induced by a rough
surfaced calculus, -or to that constant suffering produced by a phosphatic
covered stone moulded to an abraded and inflamed pelvis. It is usually
moderate, though exacerbated by exercise, jolting, jarring, local pressure,
or injudicious diet. During the acute attacks the pain may radiate along
the ureter to the groin, testes, or to the thigh, calf of leg, and foot. When
moderate the pain can often be covered with the thumb pressed into the
angle which the last rib builds with the erector spinse muscle ; any per-
cussion of the spine or succussion of the body will cause in some cases a
cutting pain to be felt in this position (Jordan-Lloyd).

It sometimes happens in the acid group that the pain of the calculus
may subside altogether in the kidney, and be felt only in the epididymis or
ovary, or calf, or sole of foot. Thus I removed an oxalate of lime stone
from the right kidney of a man who complained of incurable neuralgia of
the right testis. I operated on learning that severe right renal pain
preceded the pain in the testis by two years.

Influence of Sleep Posture on Renal Pain due to Stone. — In a certain
number of cases, large enough to warrant the symptom being asked for and
noted, the pain of renal stone is influenced by the posture of the body in
sleep. In a certain percentage of the cases the patient must lie upon the
affected side to obtain sleep. To lie on the opposite side induces or
increases (by " dragging " ?) the pain of the stone. If the renal pain is
intermittent this posture is only assumed during the exacerbation. When
the kidney has become inflamed the patient often lies on the other side,
leaving the inflamed kidney free from pressure.

B. Renal Colic Group. — It is allowed that the agony of renal colic is due
to spasmodic contractions of the renal pelvis and ureter. This is generally
induced by the passage of a calculus along the ureter, or by some other
foreign body such as a clot, a clump of muco-pus, a mass of debris or
growth, hydatid or worm. Any substance, in fact, which excites the
muscular contractions of the tube, by direct irritation of its inner surface,
and by obstruction to the free flow of urine along its channel, will cause
more or less severe renal colic. But typical renal colic is not always caused
by the transit of voidable stones.

An unvoidable calculus in the pelvis may so abut upon the orifice as to
close it and produce a colic ; or a small calculus may be so encysted near
the pelvic orifice of the ureter as to cause transient swelling sufficient to
close the opening and induce renal colic. In both cases the renal colic will
be fruitless — no stone will pass — though the symptoms may be as severe
as if a stone were in transit.

Benal colic, then, is significant of back pressure and distension of the
pelvic cavity — one of the potent factors in the production and accentuation
of suppurative changes about a renal calculus.

KIDNEY, SUEGICAL AFFECTIONS OF 61

If, then, attacks of fruitless renal colic are suffered from, the practi-
tioner may be certain that the pelvis is dilating, and on this account
the prognosis is graver than one with unilateral renal pain without colic,
and I believe operative interference should be undertaken sooner in those
with colic than in those without. It must be remembered that a pelvis
may dilate quietly without any colic, as occurs in slight bends of the
ureteric tube, narrowed vesical orifice to the ureter, and vesico-urethral
obstructions.

Other Symptoms of Eenal Stone. — Hematuria. — Slight hematuria
after exercise or jolting is the cardinal symptom of renal calculus. It may
be absent, or appear only rarely. It may occur without pain — be an early
symptom and never recur; it may be the only symptom present. It
differs from the hematuria of growth in that bleeding from a growth is apt
to occur during sleep, at which time the bleeding of calculus, depending as
it does on movement, is diminished or quiescent (Dickinson).

Nausea and vomiting is usually present during an attack of renal colic,
but it occurs also in renal pain — in some instances it is undoubtedly due to
reflex irritation — in others it indicates interference with urinary excretion.

Frequency and imperious desire to urinate are uncertain symptoms.
I believe they often indicate descending waves of pelvic or ureteric
congestion.

Pus — acid pyuria — more marked on rising; intermittent in quantity,
is an evidence of pyelitis, and therefore of great importance in prognosis.

Motile organisms in acid pyuria with renal pain, if no previous instru-
mentation has been carried out, are evidences of pelvic infection, but neither
pus nor bacteria are characteristic symptoms of stone, though valuable in-
dications of the urgency and dangers of stone.

Diagnosis. — The following Group of Symptoms arouse the Suspicion of
Calculus: — Fixed renal pain, felt posteriorly, increased by abrupt bodily
movement, exercise, or jolting, radiating when severe along the ureter to the
groin or testicle, or down the thigh or to the knee or calf. Occasionally
slight renal tenderness on deep bimanual palpation, and sharp stabbing
pain elicited by percussion or succussion. Attacks of severe renal colic
followed now and again by the passage of small calculi. Attacks of hsema-
turia observed after jolting ; the blood being intimately mixed but nearly
always slight and dark in character ; inability to sleep except on painful
side. Clear urine constantly showing a marked deposit of oxalates or uric
acid. These symptoms extending over a period of three or four years
without bladder irritation at night or day point to calculus in the kidney.

Radiography of Renal Calculi. — Every case of doubtful renal calculus
should be radiographed if possible. Kidney skiagraphy is, however, still
disappointing, for the organs lie in a region of the body having great relative
opacity to the rays ; and rays of sufficient power to penetrate these parts
penetrate the calculi also and leave no shadow. I have removed a calculus
which was not detected by the X-rays, but I have seen a sufficient number
of accurate diagnoses by its means to warrant the advice given above. It
is especially the oxalate and the phosphatic-covered calculi which give the
deepest shadow.

Mimetic Conditions. — (1) Tubercle of the Kidney. — Primary tuberculosis
of the kidney induces renal pain and tenderness on manipulation, and even
renal colic in 8 per cent of the cases, but in a less marked degree. The
hemorrhage is, however, much brighter, more dependent on cold than jolt-
ing ; the urine is murky, lightish in colour, lower in specific gravity, and
contains tubercle bacillus and pus corpuscles.

62 KIDNEY, SUEGICAL AFFECTIONS OF

The patient is not forced to sleep on the painful kidney, in fact, the
opposite side to it may be selected for the sake of relief. Early pyrexia is
not absolutely reliable in the early stages, but it is a valuable indication of
destruction and absorption of tuberculous products, and characteristic, if it
follows bimanual examination or prolonged exertion. Usually in nine
months to a year vesical irritation and penile pain appears consequent upon
descending infection.

Eenal tubercle consecutive to a vesical source is invariably preceded by
irritability of the bladder and meatal pain after micturition.

Eenal tubercle consecutive to a primary epididymal tubercle is easily
recognised by the knot in the globus minor of the same side, and in most
cases by a knot in the corresponding prostatic lobe or seminal vesicle.

(2) Ascending mild septic pyelitis — induced by irrigation of a tuber-
culous or otherwise inflamed bladder — is a fruitful source of renal pain
without colic. It simulates pelvic stone very closely.

(3) Bends of the ureter from movable kidney, narrowing of ureteric tube
near the pelvic orifice have also to be considered. These may give rise not only
to renal pain, but also to colic. Frequency of micturition in the day, but not
at night, is often marked in these cases.

(4) Interstitial shrinking nephritis produces occasionally unilateral renal
pain and haemorrhage, the pain being apparently capsular and not due to
changes in the pelvis.

(5) Stone lodged in the lower ureter near the bladder should be always
carefully excluded by rectal and vaginal and vesical examination. A stone
lodged in any part of the upper two-thirds of the ureter excites symptoms
almost exactly similar to those which a stone in the renal pelvis would
evoke, whilst a stone in the lower third simulates ovarian or uterine
trouble (Sunderland).

Treatment (Medical). — Two main objects are to be aimed at — increasing
the volume of urine and diminishing its acidity.

The former is best attained by the patient taking large quantities of
rain water, boiled water, distilled water, but better still by the use of such
waters as Contrexville, Vittel, Wildungen, Kronenquelle. All these latter
are best taken warm, two hours before breakfast, and accompanied by gentle
exercise.

If pus is present such drugs as boric acid, benzoate of ammonia, and
sandal oil are of use.

In the uric acid type, piperazine, lysidine, urotropine are valuable.

In the oxalate of lime an attempt should be made to fill in and smooth
over the sharp crystals which project from the surface (cf. clinical note on
surface) by over-alkalinising the urine. Lime phosphate is thus deposited
on the stone. To this end bicarbonate of soda, the benzoates, and lithia
salts should be employed.

The good effects of glycerine are testified to by Hermann, Eichter, and
Eavaldini ; but the reason for its action in expelling gravel is unknown ;
one or two ounces are given in an equal amount of water twice a day. The
remedy is still on its trial.

The treatment of renal colic resolves itself into relieving pain, diminish-
ing ureteric spasm, and increasing the flow of urine. It is asserted that
a spasm can be aborted or relieved by tilting the patient on his head
and massaging the ureter upwards. The older remedies, however, suffice.
Hot baths, subcutaneous injection of morphia, inhalation of chloroform.
Albarran records a case in which he cut a nephritic colic abruptly short by
passing a ureteric catheter and by washing out the pelvis of the kidney.

KIDNEY, SUEGICAL AFFECTIONS OF 63

If the usual treatment for the relief of stone fails to cure the patient
within twelve months, the question of operative interference should be con-
sidered.

Advice to Patients concerning Operation. — On three separate counts may
the medical adviser be forced to tender advice to his patient concerning the
expediency or necessity of operative interference for supposed renal calculus.

(a) The patient may demand relief from pain or from recurrent attacks of
colic.

(b) The practitioner notices that the urine is changing its sterile nature
for puriform or septic characters.

(c) Sudden suppression of urine may supervene in a patient with renal
calculous symptoms, and immediate relief be urgently needed.

(a) Should renal pain be so constant and so severe as to cripple the
patient, or should renal colic recur so frequently as to hamper the patient's
pursuits, and should therapeutics have failed to relieve within reasonable
time, say twelve months, an exploratory operation should be advised. It is
hardly necessary to hesitate on the score of uncertainty as to whether stone
is, or is not present. In the absence of tubercle and carcinoma the mere
exploration of the kidney surface through a loin incision and free separation
of the fatty capsule, even if no stone is discovered, will effectually relieve if
not cure the patient of the pain induced by kink or bend of ureter, by slight
dilatation of the pelvis from narrowing of the pelvic orifice of the ureter
and by interstitial shrinking nephritis. This is probably due to fixation of
the kidney and straightening and splinting the ureteric tube by inflam-
matory products, and interference with the nerve-supply of the capsule.
The mortality in skilled hands is nil. Should, however, the kidney be
opened, and calculus be found and removed (lumbar-nephrolithotomy), a
cure is effected with a mortality of perhaps 1 or 2 per cent, provided the
urine be sterile and the surgeon judiciously gentle with the tissue of the
kidney.

(b) But should the urine be noticed to be changing from sterile to septic,
it is not now so much a question of a demand for the relief of pain on the
initiative of the patient, as of the urgent advice of the practitioner for an
operation to arrest inflammatory changes in the kidney structure. Here
the evident duty and responsibility of the practitioner increases, I submit,
in proportion to the frequency and severity of renal colic (cf. clinical note
C). His arguments are based on the destruction of renal function of one
side and the involvement of the opposite kidney (cf. clinical note D).

It has been pointed out by Newman, and accepted as axiomatic, that
the death-rate of lumbar-nephrolithotomy rises with the presence of
suppuration to 39"6 per cent. Moreover, it is to be remembered that
suppurative disease from renal calculus has a higher mortality even than
suppurative disease of the kidney from other causes. Cases must therefore
be attacked in the sterile stage.

Henry Morris's latest statistics are still more convincing, for they
represent the work of one operator and not that of the many collected by
Newman.

In non-suppurative cases Morris lost 2*9 per cent (1 case in 34) by
the lumbar incision, but when suppuration was so advanced as to need
nephrotomy or nephrectomy the mortality rose to 25 per cent. I have lost,
without regard to aseptic or septic cases, 1 patient out of 50. This low
mortality is, however, due in all probability to the change in professional
opinion, the outcome of the above teaching, for patients in the last ten
years which cover the writer's statistics have been made to realise the para-

64 KIDNEY, SUKGICAL AFFECTIONS OF

mount necessity for early operation, and have applied for relief before the
opposite kidney has deteriorated.

(c) When the practitioner is confronted with a case of calculous suppres-
sion his duty is obvious and imperative, for calculous anuria is the gravest
and most fatal of the many serious complications of renal lithiasis, and it is
only in rare instances that the suppression, once established, is overcome.
It must be remembered that pain is the best indication both to the side to
be relieved by operation and to the appropriate time for interference. The
tender kidney, which has been the site of the pain at the onset of the sup-
pression, is to be operated on. As long as pain is experienced in the flank
or along the ureter the stone may be shifting ; directly the pain ceases and
suppression continues, the renal vitality is endangered and operation should
be considered. Let the advice for interference be urgent, be early, and, in
the stage of tolerance, between the third and fifth day {vide Calculous Anuria).
The percentage of recoveries in cases operated on is 51 per cent, as com-
pared with 208 per cent which were not operated on, but recovered spon-
taneously (Morris).

Suppression of Urine due to Calculus. Calculous Anuria. — This occurs
from the ureter becoming blocked, generally at the opening of the renal
pelvis or in its upper third, by a calculus — the other kidney being absent
(13'8 per cent, Donnadieu), functionless, or so affected by disease as to be
sensitive to reflex inhibition. It is a disease affecting mid-adult life, often
occurring in the fat and gouty. There is usually a previous history of
repeated renal colic affecting both sides with the subsequent discharge of
gravel or stone.

Onset. — After a prolonged colic, started perhaps by a sudden jerk,
exercise, a fit of temper, or apparently without cause, the patient is seized
by a constant desire to urinate, only succeeding, however, in expelling a
few drops, and that blood-stained. Then the secretion is completely
arrested.

Stage of Tolerance (Merklen). — For a variable period, at least five or
six days, the patient is in no distress, suffers no pain. He continues his
avocation, walks about strongly;' but he does not pass water, though he
may still have constant desire to do so. ' Some pass a few ounces daily of
pale urine of low specific gravity, if the anuria is not absolute. In favour-
able cases in this stage the calculus may be passed and the patient recover,
or the calculus may become dislodged, drop back into pelvis, and a rush of
many pints of urine heralds the probable return of health, though even
after this a relapse may take place. Spontaneous cure takes place in 28*5
per cent of cases (Legueu). Usually, however, general debility, sleeplessness,
and nausea supervene and usher in the stage of uraimic intoxication.

Stage of Urwmic Intoxication. — This is usually marked by the appear-
ance of hiccough, vomiting, and intense thirst. As the intoxication deepens,
muscular twitchings, pin-pointed pupils, and torpidity appear. Then comes
the drop in temperature, irregular pulse and respiration (Cheyne-Stokes),
and death between the ninth and twelfth day (or twenty-fifth day).

Diagnosis. — The history of former attacks of renal colic ; the passage of
calculi ; the sudden onset of pain in one kidney, or a prolonged colic followed
by suppression and accompanied by constant desire to urinate ; the presence
of a swelling in the renal region, of tenderness there on pressure, or along
the ureteric tract ; the appearance of a little blood in the small quantity of
urine evacuated, are points of especial diagnostic importance. Rectal or
vaginal examination to determine the condition of the lower ureter is
important.

KIDNEY, SUEGICAL AFFECTIONS OF 65

Treatment. — The only medical treatment, in the light of the pathology
of the disease, is drastic purgation — calomel is especially indicated. Opium
should he avoided, and the renal areas may be dry cupped. Operative
interference (ureterotomy, pelvotomy, or nephrostomy) must not be delayed.
It should be carried out between the third and fifth day.

LITERATURE.— Furbringer. Diseases of the Kidneys and Urinary Organs. 1898. —
Potel, quoted by Albafrau. — Dickinson. On Renal and Urinary Affections. 1885. —
Legueu. Ann. gcii.-urin. 1895. — Simon. Chir. der Niercn, ii. Theil, 1896. — Albarran.
Maladies du rein. — Jordan Lloyd. Practitioner, Sept. 1887. — Hermann. Prag. med.
Wochenschr. 1892, Nos. 47, 48. — Richter. Der arg. pract. mars 1895. — Ravaldini. II
Jiaccoglitous Med. 1893, p. 197. — Newman. Surgical Diseases of the Kidney, 1888 ; Renal
Cases, 1899. — Morris. Hunterian Lectures. 1899. — Merklen. These de Paris. ^ 1881. —
Donnadieu. These de Bordeaux. 1885.

Renal Tuberculosis

There is, perhaps, no urinary disease of surgical importance so little
understood by the profession at large or so injudiciously treated as urinary
tuberculosis. Its initial obscurity, its insidious progress, its power of mimicry,
and its extensive, often silent, invasion of adjoining sections of the urinary
tract, tend to deceive, to disconcert, and finally to dishearten the practitioner.
As likely as not, in well-meant effort to relieve the patient the medical
attendant washes out the bladder, and thus unwittingly introduces those
septic organisms which exert so baneful an influence upon the progress and
amenability of the disease. It cannot be too strongly inculcated that renal
tubercle, if it is to afford even a hopeful prognosis, should be, as it can he,
detected early and treated judiciously.

Pathology. — It is admitted that tubercle bacilli detached from any extra-
urinary focus may be swept into and collect around the glomeruli of the
kidney (Durand Fardel), and even pass out thence and be discovered in the
urine without having caused any damage, either to the glands or to their
conducting channels. A suitable nidus is therefore necessary for the
development of tubercle in the kidney, and this is probably prepared by
the deterioration of tissue induced by traumatism, pre-existing inflamma-
tion, or transient congestions of the organ.

Lines of Invasion. — The kidney may be invaded : —

A. Primarily by way of the blood stream (hsemotogenous), or

B. Consecutively by way of the ureter from some lower genito-urinary
source (urinogenous).

Each class has a characteristic initial macroscopy and a definite initial
symptomatology, and the treatment for each should, at least at first, be in
accordance with the line of invasion.

A. Primary Tuberculous Invasion of the Kidney (ff&matogenous Invasion).
— The primary invasion of the kidney assumes one of two different forms
— the acute miliary and the chronic caseating.

Acute miliary tuberculosis of the kidney is devoid of interest, for it is
the outcome of a general systemic infection arising usually from a deposit
in the lungs. It occurs principally in children. It attacks both kidneys,
is not usually diagnosable, is quite inoperative and uniformly fatal. Hence
the practitioner concerns himself with the second — an important and often
amenable class — the chronic caseating form.

A. Primary Chronic Caseating Penal Tuberculosis. — The initial stage of
this form is nearly always unilateral. Its comparative frequency is still
debatable ; but there is no doubt that disease in this organ is more commonly
met with than is generally believed (Israel).

vol. vi 5

66 KIDNEY, SUEGICAL AFFECTIONS OF

Its microscopy is as follows : — A few miliary tubercles, produced by the
irritative action of tubercle bacilli deposited from the blood stream, form in
the connective tissue at the junction of the cortex and medulla, or imme-
diately under the mucous membrane of the pelvis. These pass through the
usual well-known changes until the final caseous necrosis stage is reached.
By the coalescence of these isolated necrotic groups larger areas of disin-
tegration are formed, whence fresh infection spreads outwards to the cortex
or inwards towards the pelvic mucous membrane. Instead of an initial
shower of tubercle bacilli producing discrete nodules, a single thrombus of
tuberculous material may become lodged in and block a small renal vessel.
The plug softens and invades the surrounding area to induce like changes.
No matter what or where the anatomical starting-point of the deposit, the
final shape, size, and destruction of the kidney depends upon the attitude of
the tuberculous mischief towards the mucous membrane of the orifice of
the pelvis. Early narrowing or occlusion of this opening leads to pyo-
nephrosis and rapid destruction ; whilst patency, by permitting the discharge
of tuberculous debris and urine, allows the gland to become gradually im-
paired, the capsule to be invaded, even the capsule and fatty envelope to '
Be enormously thickened and cartilaginous, without septic suppurative
changes taking place. As the former condition is marked by colics, and
the latter by fixed renal pain, an important clue to the prognosis is obtained
by noting the extent and the character of the initial suffering.

B. Ascending Renal Tuberculosis, consecutiveto lower Genito- Urinary Tuber-
culosis. Tuberculous Pyelonephritis. — It is an open question whether there
is not in all cases of invasion from a lower urinary source an ascending
wave of simple ureteritis prior to those anatomical conditions which are
recognised as tuberculous ureteritis. In a genital invasion the kidney may
be affected without the bladder being involved. Be this as it may, the
earliest appearance of infection of the kidney from a lower source is a tuber-
culous change in the lower calyces of the kidney. If the invasion has
ascended via the ureter, it attacks the papillce of the lower third of the
kidney ; if it has short circuited from the epididymis via the lymphatics of
the vas to the lymphatics of the ureter, the submucous layer of the lower
calyces seems most often affected. The parenchyma of the kidney is then
consecutively invaded by progressive extension along the lymphatics and
vessels running towards the cortex from the lower papilke. Once started,
the changes which ensue, the gradual erosion of the pelvic mucous membrane,
and the hollowing out of the parenchyma of the gland, resemble those which
are noticeable in primary renal tuberculosis.

It is, of course, to be understood that tuberculous disease in the neigh-
bourhood of the kidney may involve that organ by direct continuity. Thus
in psoas abscess, in rare instances, the ureter may be perforated and the
disease. extend upwards to the kidney and downwards to the bladder. I
have met with two such cases on the post-mortem table. In still rarer
instances an empyema may perforate the diaphragm, surround and involve
the kidney. Such cases of infection by continuity are, however, too un-
common to merit more than this — a passing reference.

Clinical Notes based on Pathological Conditions. — 1. Extent of Renal
Tissue involved. — Primary renal tuberculosis is at first unilateral. This is a
rule upon which the practitioner may usually depend. Hence in the
earliest stage the disease is often sharply localised and therefore removable
by operation.

There is no symptom or group of symptoms by means of which one can '
accurately gauge the extent of destruction of the kidney tissue. One can

KIDNEY, SURGICAL AFFECTIONS OF 67

only assume that when renal colics are a marked feature — that is, when a
narrowed outlet exists — the destruction is greater and more rapid than
when the ureter is sufficiently patent to admit of the escape of urine and
debris. Should the ureter become suddenly and permanently blocked in
the earlier stages before septic infection, the kidney may first swell and then
gradually shrink ; under such conditions the kidney power is destroyed, and
the opposite kidney takes on the renal function. Should, however, the
kidney become blocked after septic infection, the kidney must become
pyonephrotic, and the collection of pus, urine, and debris, if unrelieved,
will perforate the capsule and form a perinephritic abscess of an especially
destructive character. Hence attention is especially directed to a cross-
examination for the symptom of renal colic. Additional evidence is
obtained by a bimanual examination of the size of the kidney and in the
aspect of the urine whether it is clear (blocked ureter) or murky (open
ureter).

2. The Rules of the Spread of Renal Tubercle. — Primary renal tuber-
culosis, as has been stated, is usually unilateral (80 per cent, Albarran).
One organ is affected to begin with. As the disease spreads and cripples
the secretory power, the fellow-gland becomes hypertrophied compensatorily.
In the ascending invasion the same rule holds ; one ureter, its pelvis, and
its kidney is attacked before the other, the ureter and pelvis being generally
inflamed before the tubercle develops in it.

If the invasion be from a primary bladder source there is no clinical
rule as to which kidney will become affected, though it is likely that any
known pre-existing inflammation of that gland will serve to locate the
disease.

There is, however, a rule as regards the side first affected in invasion
from a genital source. That side on which the disease starts is first affected
in 80 per cent of the cases. Thus, right epididymal tubercle, or right-sided
vesico-prostatic tubercle, is followed by right-sided renal tubercle.

3. The Stress Resistance of the Felloio-Kidney. — The excretion of the
toxins of primary renal tuberculosis is carried on by the opposite healthy
gland. A very gradual but distinct deterioration in the renal function is
noticeable, and it is supposed that an interstitial nephritis gradually results
(Albarran). As the tissue degenerates, it becomes very vulnerable to
ascending waves of inflammation from the bladder, which must become in-
volved in tuberculous processes descending from the original focus. If the
action of the fellow-kidney is not cut short by suppression, as so often
happens, it becomes, in its turn, the seat of destructive tubercle.

4. The Chronology of the Disease. — Like tubercle in other regions, renal
tubercle obeys no law of progress. Much depends upon the active or torpid
character of the initial deposit, upon the suitability of the nidus, upon the
part of the kidney first invaded (the parenchymatous deposit probably
developing slower than one near the pelvic mucous membrane) ; upon the
condition of the pelvic orifice of the ureter, upon the incursion of septic
microbes from the bladder or gut, and, finally, upon the inherited resistance,
nourishment, and hygienic surroundings of the patient.

Dissemination is specially retarded by early and permanent occlusion of
the ureter, and by the formation of a thick fibroid envelope around the
kidney, induced by leakage of irritating material through the cortex. This
condition merits a passing allusion. When the tuberculous process assumes
a chronic type the perirenal fat becomes invaded, and infiltrated, and
sclerosed, and the diseased kidney is finally imprisoned in a dense cartila-
ginous material. At the same time the intimate connection of this armour

68 KIDNEY, SUEGICAL AFFECTIONS OF

with the vessels and surrounding viscera renders any attempt at dissection
hazardous in the extreme. In such a case subcapsular nephrectomy is
indicated. (Compare Operations on the Kidney.)

In the larger number of cases the disease in the kidney has extended to
other parts before the third year, though from a variety of causes it may
remain torpid or only progress very slowly — possessing a life history ex-
tending over 10 or 15 years.

I submit that a slender basis in the estimate of the duration or rate of
progress of the disease is afforded by the clinical aspect of the hematurias.
Bursts of sharp hematurias are indications of torpidity.

5. On the Macroscopy of Renal Tubercle. — The final shape and size of
the diseased gland is irrespective of the character of the invasion. But
there is much clinical evidence to be obtained in determining the character
of the tumour.

(a) It may be Unfeelable. This happens when the disease is in its
earliest stage, or in its latest obsolescent stage. In either case a kidney
may be so small and fixed so high up under the ribs as not only to be
unfeelable, but to be also insensient to pressure. This occurs both in
primary and consecutive renal tuberculosis if the disease is very chronic,
if the upper part of the cortex is inflamed, and if the ureter is open
Unfeelable kidneys are rarely accompanied by pyrexia.

(b) It may form a definite, smooth, but irregular, movable tumour.
This type is usually the result of primary tuberculosis with more or less
intermittent occlusion of the ureter, forming slight pyonephrosis. The
temperature is in this case usually slightly raised (99° F.) at night. If
septic pyelitis coexists the temperature rises much higher (101° F.) The
tumour is tender in proportion to the inflammation. Very rarely is a huge
tumour tuberculous throughout ; when such exists it is called " tuberculose
massive " (Monti).

(c) It may present itself' as a large fixed mass in the loin. Such a
condition occurs usually as a leakage through the cortex, leading to
enormous thickening and matting of the periadipotic capsule, or even
perinephritis (cf. end of clinical note 4).

It is of importance for the surgeon to remember that the kidney may
appear to the eye and be to the touch absolutely healthy, and yet be
extensively ulcerated by tuberculosis at either extremity of the pelvis.

6. Clinical Note on Morbid Additions to the Urine. Formation and
Passage of " Dirt " Stones.— True renal calculi of the acid type (vide " Benal
Calculi ") are extremely rare, but it is not uncommon to find phosphatic grit,
or phosphatic scale-like concretions in a tuberculous pelvis or even lining
the entire ureter. These may be the result of ulcer crusts, or even be
phosphatic material which has become deposited upon scraps of debris. To
find a single phosphatic cast of the pelvis is very uncommon. These
"dirt" scale -stones add to the pain, the haemorrhage, and the ureteric
obstruction. They may cause colic, but their form, if they are evacuated,
is distinctive and should not mislead. Eadiography cannot differentiate
such dirt scale-stones from phosphatic-covered calculi.

7. Clinical Note on the Detection of the Bacillus Tuberculosis. — The
presence of the tubercle bacillus in clear, sterile urine is not pathognomonic
of urinary tuberculosis, for the bacilli have been found in the urine of those
who were suffering from phthisis, or from tuberculous bone or joint affection.
If, however, they are found in the pyuric urine of those who complain of
urinary symptoms, there is but little doubt of their having " effected a
destructive lodgment in some part of the urinary tract."

KIDNEY, SUKGICAL AFFECTIONS OF 69

Much stress is laid upon the similarity of tubercle bacillus to the
smegma bacillus, and many urge that the specimens examined should be
obtained by aseptic catheterism. It is held by some that there is a special
grouping of the bacilli in renal tuberculosis — that in this disease they
become massed into groups resembling the letter S.

It is, I believe, an impression, neither proved as yet nor accepted, that
tubercle bacilli are more easily and more abundantly found in renal than
in vesical tuberculosis even before putrefactive bacteria have contaminated
the urine. When the urine is decomposing in the bladder from septic
cystitis tubercle bacilli are not found. It is generally noticed that once
the bladder has been subjected to a course of irrigation tubercle bacilli are
not found, or only discovered with difficulty.

The same statement may be made for urine examined soon after a
course of injections of Koch's new tuberculin.

8. Clinical Note on the Addition of Septic Microbes. — The especial danger
to the patient lies in the introduction of septic microbes. This takes place
in some cases from contagion with the colon, but in many it is, I am certain,
the outcome of injudicious interference with the bladder, this interference
taking the form of careless irrigation, rough sounding, unskilful cystoscopy,
and the like.

It cannot be too strongly insisted on, that the practitioner can do
infinitely more harm than good in the majority of cases of urinary tuber-
culosis by washing out the bladder, for the septicity which is thus introduced
ascends by way of a weakly resisting ureteric mucous membrane to the
pelvis, and destroys the renal-secreting tissue of that organ very rapidly.
I state most emphatically that a kidney affected by tuberculosis is ruined
more quickly by bladder washing than by the destructive action of the
tubercle. Every careful practitioner will obtain, if possible, a bacteriological
report of the urine of a young adult patient, who has a causeless mild
cystitis, before he irrigates the bladder as a curative measure for the
inflammation.

Symptomatology. — A. Symptoms of Primary Renal Tuberculosis. — In a
small proportion of cases the disease commences and progresses to the
entire destruction of the gland, without evoking any marked symptoms ;
but this is rare, and there is usually certain pronounced symptoms which
may lead one to suspect primary renal tuberculosis. These symptoms are
renal pain coexisting with pale, feebly acid or neutral, murky urine of low
specific gravity, and occasional hsematurial attacks. There may not be, and
frequently is not, at first that anaemia, that rapid emaciation, and that
elevated evening temperature, upon which physicians place so much
reliance. These symptoms appear later in the disease, it is true, but not at
first, unless the renal tubercle has become affected by septicity from the
bladder ; or as some writers assert, unless the parenchyma of the gland is
much destroyed without any implication of the pelvic mucous membrane.
The cases range themselves in two distinct classes : (a) those with fixed
renal pain ; (b) those with renal colic.

(a) Tuberculous Kidney evoking fixed Renal Pain and early Pyuria. —
This class is much more commonly met with (80 per cent). The symptoms
seem to depend on the destruction of the pelvic mucous membrane and
renal structure, the urine and debris .escaping freely along the open
channel of the ureter. Although there may be some thickening of the
walls of this tube from ureteritis, yet the channel is wide enough to carry
off the secretion without exciting renal colic as a general rule, though
occasionally a clump of mucus or debris may be caught, and may give rise

70 KIDNEY, SUEGICAL AFFECTIONS OF

to a sharp ureteric twinge or even a colic. The pain is at first slight,
intermittent, disappearing for weeks, but reappearing in a more severe form
until it becomes constant. It is chiefly felt behind, over the lower ribs ; it
is coverable with the palm of the hand (not the thumb, as so often appears
to be the case in oxalate of lime stone).

After a few months the patient becomes liable to transient attacks of
frequency of micturition of greater or less severity, and meatal pain after
the act. These attacks will vary in duration, last from a few hours to a
few days. They may be due to the caustic action of the urine or to
transient waves of descending pyelitis : probably the former, for it is con-
ceivable that now and again ptomaines from the ulceration or other
chemical substances produced by the disintegration of the tuberculous
processes are added to the secretion which, passing over the sensitive neck
of the bladder, evoke temporary dysuria.

As months pass the renal pain ceases, but coincident with its subsidence
appear those symptoms which are characteristic of the disease having
effected a permanent lodgment in the bladder; habitual frequency of
micturition, diurnal or nocturnal, glans or meatal pain after the act, and
occasional slight haemorrhages.

When the bladder has become definitely ulcerated there is a " posture "
symptom of some value which may be present in women. When the
ureteric orifice has become ulcerated the patient cannot sleep on that side
at night, for this position aggravates the irritability of the bladder. The
patient, therefore, sleeps on the side opposite to that of the diseased ureter.

This brief sketch delineates the usual course in primary renal tubercle,
but it must be remembered that exceptionally the disease in the kidney is
more or less " latent," and it is only when the bladder becomes affected by
descending changes that any symptoms appear. Moreover, these symptoms
are referable to the bladder, and the disease is supposed to be primary there
because the symptoms first complained of can be located there. The
cystoscope alone detects these latent cases, for by its means the ureteric
orifice of the diseased kidney is shown to be ulcerated, or patulous, or
displaced by tuberculous changes.

(b) Tuberculous Kidney evoking Renal Colic. — Primary tubercle of the
pelvis of the kidney may, in the minority of cases (20 per cent), produce a
renal colic almost exactly like that of renal stone, and this almost from the
onset of the disease. The first symptom may be a renal colic, and this may
continue on and off until the kidney has given up secreting urine. The
colic is due to the narrowing of the pelvic orifice of the ureter and to
thickening of the ureteric wall. It is surprising how thick the ureter can
become ; some are the thickness and solidity of thumbs or forefingers, and
on section a tiny circle represents all that is left of the ureteric channel.
I venture to suggest that in such cases there is an inherited tendency to
fibroid phthisis. I believe that when such kidneys are shut off early by
occlusion of the ureter, the lymphatic trunks of the channel become plugged
and the disease is walled in. Anyway the patients who have early occlusion
seem to have a longer lease of life and to be the most favourable for cure
by nephrectomy.

Other Symptoms of Primary Eenal Tuberculosis. — (a) Formation
of Tumour. — It is generally accepted that primary renal tuberculosis
rapidly transforms the kidney, and so enlarges it as to cause a definite
tumour to be formed. This is inaccurate. It does enlarge it, but as often
as not no renal tumour can be felt in men ; and in women, who are of
laxer habit, the renal swelling can only be discovered with difficulty.

KIDNEY, SUEGICAL AFFECTIONS OF 71

When a renal tumour is found it indicates great destruction of the kidney,
either by progressive infiltration, or by pelvic dilatation from a narrowed
orifice. The practitioner, however, has to decide as to whether the kidney
which he finds enlarged is a tuberculous kidney or one compensatorily
hypertrophied. This is generally decided by the history of pain. An
hypertrophied kidney has an uneasy ache, but a tuberculous organ gener-
ally causes decided suffering. Moreover, the cystoscopic appearances of
the vesical orifices of the ureters differ, as I have just mentioned. The
ureteric catheter settles the point, for by it secretion from the kidney is
obtained direct.

(b) The Hematuria of Primary Renal Tuberculosis. — Attacks of
profuse hematuria from the kidney may antedate the characteristic
symptoms of primary renal tubercle for months — even years. The prac-
titioner is sometimes unable to locate it without the use of the cystoscope,
for it may occur without any guiding symptoms as to its source, but this is
unusual, for some renal pain and tenderness is generally present. The
attacks are apparently causeless. As often as not tubercle bacilli cannot
be found, for the amount of blood in the sample renders the detection of
the bacillus difficult if not impossible ; whilst in many instances the
disease has not really broken into the pelvis, and the debris containing
the bacilli is not yet free. A small collection of crude tubercle under the
mucous membrane of the pelvis may suddenly evoke localised pelvitis and
extravasation of blood, and this patch, small as its area may be, is sufficient
to provoke a very arterial hsematuria for a few hours. But these attacks
are nearly always as transitory as they are alarming.

It is only later, when the disease has eroded the mucous membrane and
opened the venous plexuses near the papillae, that the bleeding becomes
intractable. In the intervals of these later hsemorrhages the bacillus is
usually found in the urine without difficulty, and the secretion has the
ordinary characteristics of tuberculous urine.

(c) Polyuria. — Some stress is laid upon the fact that the patient may
pass large amounts of urine prior to the development of renal symptoms of
tuberculosis, and this symptom is ascribed to the irritation of parenchy-
matous deposits of tubercle. It needs much circumspection before allow-
ing this symptom to influence the diagnosis, for polyuria is often a transient
feature in the course of many renal diseases.

(d) Morbid Changes in the Urine. — The urine of pronounced renal
tubercle is characteristic. It is light in colour, murky with mucus, deposit-
ing a fine layer of pus and a few caseous clumps. It is always albuminous.
It is faintly acid or neutral, and of medium specific gravity. Bacilli are
discoverable, and if the urine is injected into guinea-pigs subcutaneously, a
typical tuberculosis is produced in a fortnight or three weeks.

Later, as the disease advances, putrefactive bacteria cause an offensive
odour, and muco-pus in large quantities is passed ; pus increases in propor-
tion to the grade of pyelitis.

B. Symptomatology of Consecutive Renal Tuberculosis. — The
Ascending Form. — The kidney in many cases is invaded by tuberculous
changes which originate in the lower genito-urinary organs, and under
these circumstances there are always pronounced symptoms attending the
site of origin. If the bladder be the primary site there is the history of
frequent micturition, especially at night ; pain after the act, at the meatus
urinarius or glans penis, suprapubic pain on over-distension and slight
hsematuria ; or if the epididymis has harboured the primary focus, a history
of causeless abscess or thickening of that body is always ascertainable.

72 KIDNEY, SUEGICAL AFFECTIONS OF

The practitioner cannot be too exacting in cross-examination for these
symptoms, for the line of treatment to be adopted depends upon whether
the form be primary or consecutive implication of the kidney.

Diagnosis. — The renal conditions which resemble renal tubercle fall
into two groups, the early appearance of pus in the urine serving, although
roughly, to mark the division.

The first group. — Calculus of the kidney, movable kidney, and renal
tumours rarely produce puriform urine in their earlier stages, whilst pus
appears very early in renal tubercle.

From the second group, which includes septic interstitial nephritis,
septic pyelitis, and pyonephrosis, the tuberculous disease of the kidney is
separated by the fact that it produces marked night frequency and other
vesical symptoms. Moreover, from both groups it can in course of time be
distinguished in the male by the inevitable progress and invasion of the
genital organs ; for a tuberculous deposit can always be discovered as the
disease advances, in the epididymis of the same side, or the vesiculse or
prostate. The great element in accurate diagnosis is the discovery of the
bacillus in the urine. The cystoscope, if skilfully handled, is often of
prime importance in detecting which kidney is affected (q.v.)

Prognosis. — The prognosis in unilateral primary renal tuberculosis is
very grave ; in the ascending form it is almost hopeless. Concerning the
former it may be said that occasionally it obsolesces, as in fact tubercle can
and does in other parts of the urinary tract. Evidences 'of this natural
cure are occasionally found on the post-mortem table, but it is a consumma-
tion that is probably rare. It is possible for a tuberculous deposit in the
kidney to slough out and come away by the ureter with the urine, but it is
not common.

The favourable cases are those in which the ureter becomes choked
early in the course of the disease, and before septic material has had access
to the pelvis, in which case the secretion of urine ceases, the kidney con-
tracts and remains quiescent, the fellow-gland doing the work of the
body.

The useless kidney is, however, liable to recrudescence on the inter-
currence of some debilitating fever such as epidemic influenza. Even a
cold, a wrench of the body, or a blow on the loin, will start the disease
afresh.

Treatment. — It will be remembered that the disease in the kidney,
when primary, remains localised for months ; and it is in this stage that
the chance for operative interference curing the disease is greatest. It is
in this period that the acumen and judgment of the practitioner is of such
vital importance to the future well-being of his patient. I cordially agree
with the justice of Newman's remark that the practitioner who makes an
early diagnosis in a case of primary renal tuberculosis renders a service to the
patient as valuable as that of the surgeon, who at a later date performs a
successful nephrotomy or nephrectomy.

Serum Therapy. — (a) In the " fixed renal pain " group.

If tubercle has oeen found and there are no symptoms of bladder irrita-
tion, a course of Koch's new tuberculin should be tried, on the chance that
the disease is limited, and that it may become so affected by the injection
as to break down and pass by the natural channel, for we are quite unable
to say how much of the kidney is affected. A course of six injections is
cautiously given, one every third day into the thigh, the skin being first
carefully cleansed with soap, carbolic lotion, and finally ether — a Liier
syringe is the best form of instrument to employ. The initial dose is

KIDNEY, SURGICAL AFFECTIONS OF 73

-„ I-j rag., and the strength is gradually increased thus (?%?, Yhr> i1d> ihr>
•j-V, 1 mg. The injections are suspended if fever or renal pain
develops.

If tubercle cannot be found in the urine it is of paramount importance,
in cases where the family history of phthisis is marked, to cystoscope and
examine the ureteric orifice and its immediate neighbourhood.

(&) In the renal colic group.

In treating primary renal tuberculosis marked by renal colic, I object
to the use of Koch's tuberculin, for I hold that the renal colic is absolute
evidence of the tuberculous invasion and thickening of the ureteric channel,
and the swelling of the deposit in the wall of the tube caused by Koch's
tuberculin is quite sufficient to block the tiny channel which remains. The
debris and broken down tissue which is released in the kidney cannot pass and
are therefore retained. Swelling of the organ ensues and extension of the
disease follows, for the thick inflammatory wall which the disease has
already constructed around the dangerous foci is overstretched and per-
forated. It is probably better in the renal colic class to nephrectomise
immediately after cystoscopy of the ureteric orifice.

Treatment of Ascending Renal Tuberculosis.— The treatment of ascend-
ing renal tuberculosis depends largely upon the cystoscope. An examina-
tion of the ureteric orifices under the electric light determines if and which
kidney is affected, and how far the ureter is involved, also whether the
bladder is so far ulcerated as to render remediable measures of value. If
the ulceration in the bladder has not advanced to the muscle area-, if it is
limited to patches in the postero-superior wall, if one kidney is decidedly
affected, I nephrectomise the diseased gland, taking away as much of the
ureter as possible, and after the patient has healed I treat the bladder by
means of Koch's new tuberculin. But I hold it a doubtful expedient to use
serum therapy in the ascending form of renal tuberculosis until the kidney
has been removed.

Medicinal. — Neither the fixed pain nor the renal colics are severe as a
general rule ; both are amenable to opiates. The administration of small
doses of sandal oil in capsule relieves the pyelitis, hexamethylentetramine
(gr. v.) or boric acid, ammonic benzoate, or salol, keep the urine as sterile
as is possible. Creasote occasionally seems beneficial. Methylene blue in
pill is worthy of a trial.

When the disease has reached the bladder its distressing effects must be
combated on the principles laid down for cystitis, the practitioner bearing
in mind the intolerance of the urethra to instrumentation and the resent-
ment of the tuberculous bladder to irrigation. Strict hygiene, a generous
diet, with fat and sugar, if these articles are well borne by the digestion ; a
high and dry climate, if obtainable, — are all that can be done to alleviate and
arrest the spread of the disease. Care should always be taken to impress
upon the patient the necessity for adding carbolic acid to the chamber
utensil in order to prevent the spread of the disease. The following experi-
ment endorses the wisdom of such a proceeding. Five rabbits were confined
in a box and made to breathe vapour from an atomizer charged with the
urine of two phthisical patients. After a couple of months all the animals
were found markedly tuberculous.

Operative. — For primary renal tuberculosis.

Operative. — Two courses are open. If, on exploration, the disease is
limited to a single cavity or to a small area, nephrotomy may be performed
and the entire disease curetted out. Against this is the great uncertainty
as to how far the disease has involved the gland, and the danger of allowing

74 KIDNEY, SUKGICAL AFFECTIONS OF

tuberculous material to foul the operation wound and the exposed perirenal
tissue.

Nephrectomy or nephro-ureterectomy is the operation which must be
performed in most cases, even when taken early ; by it the disease is re-
moved absolutely, and with it the greater part of the ureter ; the remainder
of this tube being curetted or energetically dealt with. The same operation
is advocated for suitable cases of ascending renal tuberculosis.

Advice to Patients concerning Operation. — Advice to the patient anent
operation in renal tuberculosis should rest finally and entirely with the
operating surgeon. Upon his judgment must the necessity, the advisability,
and the danger of nephrectomy depend. His must be the consideration of
the exact stage which the disease has reached ; his the determination of the
stress resistance of the opposite kidney. This being made clear to the
patient, the following statistics will be of value in discussing the considera-
tion of operation.

Bolton Bangs of New York has collected cases from various sources.
They are selected since 1888, for the means of diagnosis have been so im-
proved since then by the perfection of the cystoscope and the catheterisation
of the ureters, that statistics taken prior to that date are misleading.

135 cases are quoted. The immediate operative mortality was 20 per
cent.

Immediate Mortality.

Uraturia . . . . .11 cases (42 per cent).

Various accidents . . . . 11 ,,

Exhaustion . . . . . 2 ,,

Extension Tuberculosis . . . 3 „

27 out of 135 = I or 20 per cent.

Later Mortality.

Died within nine months . . . . . .13 cases

Survived and fairly well up to nine months . . . 31 „

Survived one to eight years . . . . . 45 „

Half the cases, then, were very favourable, some living as long as eight
years. Dr. Bangs remarks : —

" The first and undoubted conclusion which these statistics warrant is
that the immediate result of the operation for renal tuberculosis in the
cases in which it is indicated is brilliant. Many cases which seemed in
extremis and liable to speedy death from hectic hyperpyrexia, pain, etc.,
were immediately relieved, their existence made tolerably comfortable, and
their lives prolonged. A clear and positive conclusion of the remote results
is exceedingly difficult to reach ; still I think the opinion based upon
such statistics as I have been able to get is warranted that operation affords
better remote results than hygiene."

LITERATURE.— Durand- Fardel. These de Paris. 1886. —Israel. Deut. med.
Wochenschrift, 1898, xxv. 443.— Idem. Gentralblatt fur Chir. 1898, xxv. 23.— Bangs.
Ann. of Surg. Phil. 1898, xxvii. 14. — Facklam. Archiv f. Klin. Chir. 1893, xlv. 715.
— Newman. Lancet. Aug. 1899 and Feb. 24, March 3 and 10, 1900. — Posner. Congress
on Tuberculosis at Naples, 1900, B. M. J. May 26, 1900. — Konig. Deut. med. Wochenschr.
1900, xxvi. 111.— Goldberg. Centralbl. f. d. Krankh. d. Ham u. Sex. Org. 1897, viii. 469.
— Carlier. Ass. franc, d'urol. Proc.-verb. 1897, Paris, 1898, ii. — Loumeatj. Ass. franc,
de Chir. Proc.-verb. Par. 1897, xi. — Savariaud. Gaz. de hop. Par. 1898, lxxi. 821. —
Bizaquet. These de Paris. 1898.— Pissavy. These de Paris. 1898. — R. Park. Jour.
Cutan. and Gen.-Vrin. Dis. N. Y. 1898, xvi. — Monti. "Krankh. der Niere," Gerhardt's
Handb. d. Kinderkrankh, iv. — Albarran. Maladies du rein. — Hurry Fenwick. Ulcera-
tion of the Bladder — Simple, Tuberculous, and Malignant. 1900.

KIDNEY, SURGICAL AFFECTIONS OF 75

Hydatid Cysts

Hydatid cysts are comparatively rarely met with in the kidney, form-
ing only 5 per cent to 8 per cent of all hydatid disease (Davaine, Neisser).

The cyst is usually limited to one kidney (98 per cent, Beraud), often
the left, and starts in the cortex. As it increases in size it projects from
the surface of the organ and encroaches upon the renal pelvis. It frequently
bursts into that cavity (82 per cent of the cases, Roberts). In size it may
vary from that of an egg to that of a man's head. When feelable it forms a
rounded, painless, elastic tumour in thehypogastrium — often irregular because
of the multilocular nature of the cyst. If the contents have not suppurated
spontaneously the swelling is movable ; if the cyst has inflamed the tumour
becomes fixed. Occasionally the cyst wall is transformed into a semiosseous
envelope, and in this condition it is densely hard, and affords a striking but
misleading skiagraph on radiography. Adhesions are nearly always con-
tracted with neighbouring viscera, but they vary greatly in density. In one
case in which I had to operate for the relief of intestinal obstruction, I
found a kinked colon so adherent to the fixed bony case of a small unsus-
pected renal hydatid that I could not dissect it off without opening the gut.

When the cyst calcifies and dies, the contents are transformed into
putty-like material which is composed of fat, cholesterine, and laminated
membrane.

Symptoms may be entirely absent, and a renal swelling discovered by
accident, the patient's attention being drawn to the loin by a dull aching in
that region. The first characteristic symptom is produced by the bursting
of the cyst into the pelvis, and the passage of the hydatids or membranes
in the shape of grapes or grape skins. Urticaria has been observed to follow
rupture into the ureter (Mosler).

Usually a rigor, accompanied by all the symptoms of renal colic, precedes
the first attack, but the ureter soon enlarges and isolated cysts are passed
without much suffering, unless a collection enters the pelvis and blocks the
ureter. The cysts vary from the size of a pigeon's egg to that of a pea, but
the larger are ruptured and are passed as mere collapsed sacs.

It is astonishing for how many years these attacks continue. One of
my patients stated that he had thus suffered for thirty-one years : another
that he had noticed the renal tumour for thirty years, but had only passed
the cysts for five years.

Suppuration sometimes takes place in the tumour, I suspect, as a con-
sequence of its intimate adherence to the colon, and instead of sterile urine,
a thin, gruel-like urine, laden with pus, broken cysts, and large fragments of
laminated membrane, is passed. I have treated a case of renal hydatid
which discharged along the ureter for thirty years before suppurating.

Diagnosis. — The presence of an elastic renal tumour in conjunction with
attacks of renal colic of that side and the passage of an hydatid cyst, either
whole or collapsed, is, of course, absolute indication of a renal hydatid. It
has been pointed out that hydatid cysts may be passed per urethram from
a collection situated behind the bladder, and bursting into that viscus, but
this chance may be disregarded. Only three unequivocal cases are on
record in the literature of the last 200 years. Moreover, if such a collec-
tion exists it is discoverable by rectal examination.

The diagnosis of renal hydatids based upon an elastic, uneven tumour in
the hypogastric region may be established by aspiration of fluid with hook-
lets in it from the loin ; but this method of investigation is not without
risk, for it is liable to induce suppuration.

76 KIDNEY, SURGICAL AFFECTIONS OF

Operative Treatment. — It used to be urged that these cysts, enjoying as
they seem to do long periods of quiescence (ten, twenty, thirty years), need
not be interfered with as long as the suffering of the patient is not great, and
no rapid increase in size is noticed. It is, however, to be remembered that
they gradually contract adhesions with the gut, and these may give rise to
obstruction by kinking the bowel ; or the cyst may suppurate spontaneously.
In every case also the pressure of the enlarging cyst acts injuriously on the
renal structure, and it is wiser to operate early in order to anticipate such
untoward events. It is seldom that nephrectomy will be needed. Laying
bare the surface of the cyst, incising it, stitching the fibrous capsule to the
wound, evacuating the contents, and peeling off the mother cyst, is the opera-
tion of choice. It is, I think, better to drain the cavity, but this may not
be always necessary. If the cyst is already suppurating free drainage is
absolutely requisite.

Fifteen cases treated in this way have resulted in fifteen successes, while
nephrectomy has been done five times with four deaths (Albarran).

Davaine. Traite cles Entozoaires. Paris, 1860. — ISTf.isser. Die Echinococcenkrankheit.
Berlin, 1877. — Beraud. These de Paris. 1861. — Senator. Die Erkrankungen der Nieren.
1896. — Roberts. On Urinary and Renal Diseases. 1885. — Albarran. Maladies du rein.—
Hrxr.RY Fenwick. Trans. Clinical Soc. 1891. — Ibid. International Clinics, vol. iv. 3d series,
p. 233.

Hydronephrosis

Partial or intermittent obstruction in the urinary passages causes dilata-
tion of the renal pelvis and kidney, and if the sac which is formed contains
urine the condition is called hydronephrosis. There are two forms, con-
genital and acquired.

Congenital Hydronephrosis needs but a brief reference.

In 38 per cent of all cases of hydronephrosis some congenital defect is
present (Eoberts), but the term congenital hydronephrosis is applied to the
form present at birth or soon after birth.

The condition is due to deformity of the ureter (impervious, contracted,
twisted, or kinked ureter), or to the pressure of abnormal renal vessels, or
to some abnormality in the urethra. It is sometimes present at birth and
gives rise to difficult labour. If the child survives birth it is usually fatal
in a few months or years (Newman).

Congenital hydronephrosis may be unilateral or bilateral, and other
congenital defects, such as harelip, are often present.

Acquired Hydronephrosis. — Etiology. — (1) Ureteric Causes. — Calculus
impacted in the ureter or stricture of the ureter following its passage (in
59 per cent, Roberts). Contraction of the ureter following injury, pressure
on the ureter by pelvic tumours (27 per cent, Newman), by pelvic scar tissue
from inflammation or sometimes displacements of the uterus, or pregnancy.
(In thirty-six autopsies on females recently delivered, Olshausen found
hydronephrosis twenty-five times.)

Kinking of the ureter in a movable kidney.

(2) and (3) Any vesical or urethral impediment to the flow of urine.

Pathological Anatomy. — There is dilatation of the renal pelvis, flattening
of the papillse, and gradual destruction and disappearance of the renal tissue
until only a fibrous sac remains. Sometimes it attains enormous dimen-
sions. The largest on record is one which held thirty gallons of fluid,
while the abdomen measured 6 feet 4 inches in circumference (Glass). The
sac is subdivided by septa into loculi which open into the greatly dilated
pelvis. The walls may be thick and fibrous, sometimes they are very thin.

KIDNEY, SURGICAL AFFECTIONS OF Ti

In some cases a varying amount of renal tissue remains. The cyst contains
water with a varying amount of sodium chloride and traces of urea. Some-
times mucus and epithelium are present. With the destruction of one
kidney the other hypertrophies and performs the entire urinary function.

Symptoms. — Tumour. — Often the only sign of hydronephrosis is a large
fluctuating tumour situated in the loin. In 59 per cent of cases there is a
palpable tumour (Roberts).

The loin sometimes bulges, and renal " ballottement " may be obtained
by placing one hand on the abdomen and projecting the tumour forward
with the other in the loin. The swelling is rounded on all sides, and
descends slightly with respiration. On percussion dulness extends to the
spine posteriorly, while in front the tympanitic note of the colon is obtained,
and in a tumour of moderate size a resonant note can be obtained separating
it from the liver on the right and the spleen on the left.

Pain. — The tumour, as a rule, is painless and no tenderness is present ;
often there may be slight aching, but both these symptoms depend on the
rapidity with which the hydronephrosis grows.

There is rarely hematuria, and the urine is normal in quantity and
quality.

Intermittent Hydronephrosis. — In a certain number of cases the
tumour suddenly disappears, and coincident with this there is a temporary
marked polyuria of urine of a low specific gravity. After a time the tumour
gradually reappears and again evacuates itself. Reaccumulation of the fluid
is often preceded by an attack of renal colic.

Bilateral Hydronephrosis occurs when there is incomplete obstruction
of the urethra, sometimes the cause is in the bladder, rarely in both
ureters.

If during the course of an urethral stricture a constant polyuria is
present with diminution in the specific gravity of the urine, commencing
dilatation of the kidneys may be suspected. There is often some albumin in
the urine and tube casts may be present. There is not usually sufficient
enlargement of the kidneys to be felt on palpation of the abdomen, and there
is no pain or tenderness.

These cases often have transient attacks of suppression of urine in the
later stages, and eventually die of uraemia.

Diagnosis. — (1) Of the renal tumour. (2) Of the nature of the renal
tumour.

(1) The Renal Tumour. — The history of renal colic, hematuria, pyuria,
or other urinary symptoms, if present, point to the renal origin of the
swelling.

Mimetic Conditions. — (a) Tumours of the Liver and Gall-Madder. —
These grow from above downwards, while kidney tumours pass from the loin
forwards.

They move more freely with respiration than do renal tumours. The
dulness is continuous with that of the liver, and there is- never a tympanitic
note in front. Sometimes a history of jaundice or of biliary colic may be
obtained.

(&) Tumours of the spleen occupy a higher position, are more freely
movable with respiration, the whole tumour is dull on percussion, and there
may be a well-defined edge and a typical notch. General symptoms of
malaria, leuksemia, etc., are frequently present.

(c) Ovarian cysts grow from the pelvis upwards ; if large enough to
simulate a renal tumour they are median, dull on percussion, and both loins
are resonant. The tumour is more movable than a renal one, and vaginal

78 KIDNEY, SURGICAL AFFECTIONS OF

examination shows a displaced uterus and a fluctuating pelvic tumour.
There is no urinary history, hut often one of menstrual disturbances.

(d) Ascitis may be simulated by a very large lax hydronephrosis. There
is dulness in both flanks, which shifts with the varying position of the
patient, and a percussion thrill may be obtained.

(2) The Nature of the Renal Tumour. — Hydatid and serous cysts also
form painless, fluctuating tumours of the kidney. They are comparatively
rare conditions.

In the case of hydatids there may be a history of renal colic from the
passage of small cysts. The discovery of one of the causes of hydro-
nephrosis, such as an ureteric stone felt per rectum, or the history of passage
of gravel or stone, are of importance.

Pyonephrosis. — The swelling in these cases is often tender and frequently
painful. There is usually a history of pus in the urine and rigors, and
fever will indicate the purulent nature of the contents.

Treatment. — Medical treatment is unavailing. Operative measures, such
as drainage or plastic pelvectomy, or removal of the kidney, should be advised
in all but the smallest hydronephroses. The following points are the most
important in considering the question of operation : —

(1) The patient may seek relief from the pressure effects of a very
large hydronephrosis, especially shortness of breath, palpitation, constipa-
tion, or vomiting.

(2) In bilateral cases the destruction of kidney tissue is progressive,
and eventually the issue is certainly fatal. Patients with hydronephrosis
seldom live beyond the age of 50 (Dickinson). Death occurs from suppres-
sion and uraemia.

(3) In unilateral hydronephrosis the causal condition (most frequently
stone) often becomes bilateral, and the remaining kidney is destroyed.

(4) Eupture of the hydronephrotic sac (spontaneous or from injury)
may occur with fatal results.

(5) At any time suppuration may occur in the sac by the use of septic
catheters or in other ways ; and the condition is much graver than in
simple hydronephrosis. This is well shown by the cases published by
Henry Morris. In ten operations for hydronephrosis he had no deaths, in
nine operations for pyonephrosis three patients died.

In cases due to the pressure of malignant tumours — cancer of the uterus,
for instance — operation is, of course, contra -indicated; but the question
will seldom be raised, for in such cases a renal swelling is rarely discovered
(Morris).

Pyonephrosis

Pyonephrosis is a term used to denote dilatation of the kidney and its
pelvis,- with suppuration superadded. The dilatation may occur first and
sepsis be added, either from septic catheterisation or some operation, or no
such cause may be present, and infection come through the blood stream.
In other cases the ureter becomes blocked in the course of a calculous pye-
litis and pus accumulates.

Pathological Anatomy. — The structure of the sac is the same as in
hydronephrosis, but the lining membrane is roughened, shreddy, and the
contents purulent. Frequently there is phosphatic deposit on the walls,
and calculi may be present if the condition has developed from calculous
pyelitis. If one kidney alone is affected the cause will be found in the
renal pelvis, and is almost invariably calculus. Both kidneys are often
dilated, and these cases arise from obstruction in the bladder or in front of

KIDNEY, SUEGICAL AFFECTIONS OF 79

it. In such chronic cystitis is present, and the ureters are dilated and
thickened.

The development of a primary pyonephrosis is more rapid than that of
a hydronephrosis (Morris), and also more complete.

Condition of the other Kidney. — It is seldom quite normal even in
unilateral pyonephrosis, and may be congested and inflamed, or the seat of
waxy disease (in 56'4 per cent of cases some disease is present, Turner).
When the condition follows enlarged prostate, stricture, etc., one kidney is
always more damaged than the other, and the least injured organ shows a
varying degree of suppuration and dilatation. In these cases the more
healthy kidney unfortunately does not hypertrophy, and suppression of
urine is liable to occur.

Symptomatology. — Pyonephrosis is merely a stage in the progress of
various urinary maladies. The swelling is in the lumbar region ; if large it
bulges backwards as well as forwards, the surface is usually lobulated, it
moves slightly with respiration, ballottement can be obtained. In consist-
ence it is firm, sometimes fluctuating. It is dull on percussion, except
in front, where the colonic note can be obtained. It has, in fact, the
characters of any renal tumour, and is distinguished from swellings of other
organs by the same means as a hydronephrosis.

It has certain special characteristics. It varies in size at different
times ; when the pus in the urine diminishes the tumour increases, and
vice versd. It is usually accompanied by general symptoms of septic
absorption.

Pain is seldom completely absent. It is usually a dull lumbar aching,
and is liable to exacerbations when the pus is retained and the tumour
enlarges. Sometimes it strays along the line of the ureter. Some patients
suffer a good deal, and especially after exercise, and renal colic with rigors
may occur. Pain is increased by pressure in front, but often relieved by
pressure posteriorly (White and Martin). Tenderness may be felt along
the line of the ureter (Albarran).

The Urine.— When pyonephrosis is due to "ascending" changes the
urine is always cloudy, alkaline, has a thick deposit of muco-pus and an
ammoniacal odour. When the pyonephrosis is " open " the urine contains
a large quantity of pus. A deposit of pus, representing about one-fifth to
one-sixth of the total liquid, is never produced by a bladder lesion alone.
The relieving flow of pus after an attack of retention in the pyonephrosis.
is often enormous. In unilateral pyonephrosis pus may be constantly
present in the urine (" open ") ; it may be intermittent or completely absent
(/'closed"). The urine in these latter cases is faintly acid, sometimes
alkaline. During an attack of retention in a unilateral pyonephrosis the
urine is merely the secretion of the other kidney, and valuable information
may then be obtained of the working capacity of that organ.

General Symptoms. — There is general debility, loss of weight, the appetite-
is poor, and the patient suffers from indigestion. Sickness and diarrhoea
are sometimes present, and the skin ( acquires a yellowish sallow tinge.
Fever is present in most cases ; sometimes it is slight, and if prolonged will
become hectic ; in other cases it is more acute.

When suppuration occurs in a hydronephrosis the first sign will prob-
ably be a rise of temperature, with shivering.
Two types of pyonephrosis will be met with.

(1) Where the bladder is free from disease and the pyonephrosis is
unilateral. These are mostly cases of stone in the kidney or ureter.

(2) Where cystitis is present, usually with some obstruction. Flere

80 KIDNEY, SUEGICAL AFFECTIONS OF

both kidneys are affected, in varying degree, and the cause is in or anterior
to the bladder.

Clinical Types. — (1) Pyonephrosis in a case of renal calculus.

In a case of calculous pyelitis the pus in the urine may diminish or
disappear entirely, and the urine become clear. At the same time the
patient complains of aching or increased pain in the diseased loin, some
fever appears, and there is a loss of appetite and general feeling of debility.
On examination of the loin a tumour is felt and there is marked tenderness.
The block may remain, but often after a time the pus suddenly reappears in
large quantity in the urine, the pain and fever disappear, and the tumour
can no longer be felt. This may be repeated from time to time.

(2) In a case of long-standing cystitis with obstruction the urine is
turbid, alkaline, and ammoniacal, with abundant deposit of slimy pus.
"Without any noticeable change in the urine fever appears and some aching
in the loins. The patient loses flesh, his appetite is poor, and his skin
sallow. There is tenderness along the ureter on one or both sides, and in
the loin, and sometimes a tumour may be felt. Here there is probably
retention of pus in the kidney pelvis, but the symptoms may be due to a
suppurative pyelonephritis. In the latter there is seldom a tumour, the
fever and general symptoms are more rapid and severe, and the amount of
pus in the urine is usually less than in pyonephrosis.

Diagnosis. — (a) Hydronephrosis. — The tumour is not tender and seldom
painful, there is no pus in the urine, and no symptoms of septic absorption.

(b) Tuberculous disease of the kidney is differentiated by the cheesy
character of the urinary deposit, the presence of tubercle bacilli in the
urine, the hseniaturia, and in the male the descending invasion of tuberculous
disease along the urinary tract. Often there is the history and evidence of
pre-existing tubercle elsewhere.

(c) Purulent collections opening into the bladder may cause intermittent
pyuria. The cystoscope is the best means of diagnosis.

Treatment. — Medical. — The indications are to support the strength by
tonics and to administer urinary antiseptics, such as boric acid, ammonium
benzoate, and salol.

The operative treatment of the two classes described is different. In the
" ascending " form the cause (stricture, etc.) must be attacked, the residual
urine got rid of, and the cystitis arrested. In the other class the inter-
ference is direct, and the kidney is opened and drained, or if need be
removed. Operation is to be recommended as early as possible on the
following grounds : —

(1) In unilateral pyonephrosis the other kidney may become involved
by development of stone or waxy disease resulting from septic absorption.

(2) Septicemia or pyaemia sometimes occurs, and hectic fever often
results from long-continued disease.

(3) Rupture of the sac may occur with rapidly fatal results.

(4) Suppression of urine and uraemia are prone to occur.

Kidney Tumours

Benign tumours hardly merit reference. Fibromata, lipomata, and
adenomata have been encountered, but so rarely that no clinical picture can
be formed for them as yet. Papillomata of the mucous membrane of the
pelvis, unconnected with malignant growth, is a very unusual disease, the
literature containing only eight examples. They do not increase the size of
the kidney, but give rise to hematuria of the painless type.

KIDNEY, SUEGICAL AFFECTIONS OF 81

Primary malignant disease of the kidney may be considered to comprise
three groups of tumour-forming growth : —

1. Sarcomata.

2. Carcinomata.

3. Malignant transformation of accessory adrenals (suprarenal " rests ").
Pathology. — Sarcomata are met with before the age of five and after

thirty. The microscopy at these ages differs. The tumour of childhood is
often largely composed of striped muscle fasciculi, that of the adult is com-
paratively free of this tissue. The sarcomata of childhood is apparently
congenital, bilateral (50 per cent), and attains a greater relative and even
absolute size than in the adult.

Carcinomata are probably rarer than sarcomata, they are met with
after the age of forty-five, and originate either in the cortex or in the
mucous membrane of the pelvis, the latter being a rare site.

Malignant accessory Adrenals. — Grawitz has demonstrated that tumours
composed of suprarenal elements (epithelium and zona pigmentosa) develop
in the cortex or immediately under the capsule of the kidney : ordinarily
they are no larger than a cherry-stone. These suprarenal "rests" may
become malignant in adult life, sometimes forming very large tumours.
They are extremely vascular, and this, together with the fatty material
always present, produces a characteristic red-yellow appearance. They
form secondary deposits (20 in 28 cases, Lubarsch).

Symptomatology. — In the Child. — The growth is generally rapid and
sometimes colossal ; indeed, Osier remarks that very large (solid) abdominal
tumours in children are nearly always renal or retroperitoneal sarcomata.
They are usually symptomless except towards the last, when pressure
symptoms occur. (Hsematuria in 25 per cent, Newman.)

In the Adult. — There are two salient features : (a) the appearance of a
solid irregular renal tumour — palpable and visible ; (b) the occurrence of
a causeless, usually painless, intermittent, profuse hsematuria. The tumour
may be first discovered (in 63 per cent of the cases), or the hsemorrhage
may be the onset symptom (in 37 per cent of the cases). If these two
features are present together they indicate neoplasm of the kidney.

life-History. — 1. Latent Period. — The first state is symptomless unless
it be an occasional ache or drag in one loin. The growth in the parenchyma
is either spreading towards and stretching the capsule to form a tumour,
63 per cent ; or it is pressing on and invading the mucous membrane of the
renal pelvis to cause hsematuria, 37 per cent.

2. Period of onset Symptoms. — If the growth spreads outwards to form
a tumour, and is so rapid as to distend the capsule quickly, the pain may
be a marked symptom. The pain area may cover the entire loin and
hypochondriac region, and referred pain may shoot along the distribution
of the nerves to the hip, thigh, leg, and even testicle. If the growth only
increases slowly it may cause no pain. The increase in either case is gener-
ally forwards to the peritoneal cavity ; then, as its weight increases, it tends
downwards ; on the right it tends to pass completely to the outside of the
ascending colon ; on the left it is habitually crossed by the upper part of
the descending colon (Stimson). The kidney may be sensitive in carcinoma,
but not in sarcoma (Thornton). If the growth tends to invade the pelvis
rather than the capsule, the hsematurial onset is as follows : —

The patient, apparently in good health, suddenly experiences a diffi-
culty in starting the act of micturition ; with an effort a clot is shot out,
and then a quantity of blood and urine follows. There may be a suggestion
of slight indirect violence as a cause for the blood, such as lifting a heavy
VOL. vi 6

82 KIDNEY, SUKGICAL AFFECTIONS OF

weight, or sitting heavily down on a chair lower than was anticipated.
Such slight violence lacerates a soft knot of growth fungating into the renal
pelvis. If clots are not a marked feature at the onset the haemorrhage at
first ceases quietly. If clots are abundant at the onset or in the course of
the case, the bleeding ceases abruptly, and a pain varying from a little
uneasiness to distinct localised transient lumbar pain is experienced in the
affected kidney, or even clot colic (renal) may be noticed. Cystoscopy will
show a long black or decolorised gray clot distending and hanging from
the corresponding ureteric orifice. With the expulsion of this corking clot,
which is like a worm, the bleeding recommences. Occasionally clot reten-
tion is suffered from, and the catheter is necessary. Cancer clumps are
rarely found in the clot or urine.

Pressure symptoms now arise from mere bulk of tumour, such as sudden
varicocele, oedema of one extremity, or of the abdominal wall. Even ascites
may ensue.

Period of Dissemination. — Sooner or later the capsule of the kidney
gives way, and coincident with the loss of this barrier, diffused and
increased pain is often noticeable, loss of flesh is a marked feature;
anorexia and cachexia supervene.

Diagnosis is often impossible without direct inspection, through a loin
or abdominal incision, but the presence of a renal tumour with severe
haematuria is most suspicious of growth. If the diagnosis has to be made
upon the clinical grounds of an irregular tumour in the renal region, renal
calculus with chronic perinephritis and tuberculosis have to be excluded.
Other tumours simulate renal growth. On the left side there is the
enlarged spleen, but this is readily distinguished from renal growth by its
distinct edge, its notch or notches often, by a murmur, or a pulsation, by
its creaking fremitus, and the microscopic character of the patient's blood
(vide " Blood," vol. i.). Moreover, the gut lies behind it. Hepatic growths
are occasionally confusing, but they lack that resonant zone which exists
between the upper margin of a renal tumour and the ribs. It must
be remembered, however, that in the later stages when a renal growth
fuses with the liver tactile differentiation is impossible. Malignant de-
generation of a movable kidney sometimes resembles cancer of the ovary,
but it possesses a free upward mobility at first, and pelvic examination is
negative.

Data for Advice to the Patient and Friends. — In the Child. — Statistics of
recovery after nephrectomy for the sarcoma of childhood hardly justify an
operation. The only chance of success in the adult is early detection and
early nephrectomy.

Due stress should be laid upon the following unfavourable symptoms :
extensive adhesions, immobility of tumour ; extreme thirst ; pressure
symptoms, other than varicocele ; wasting ; cachexia unaccounted for by
haemorrhage ; loss of sulphocyanide in the saliva.

The operative mortality is between 50 per cent (Guilleman) and 42 per
cent (Barth), but individual surgeons have varying success — that of 16*6
per cent being the lowest (Schede, Israel).

In my opinion and work the cases in which nephrectomy is most hopeful
are those in which haematuria is the onset symptom — those who are operated
upon directly the profuse haematuria appears. These are cystoscopy cases.
Thus I have removed kidneys in which the growth was the size of a small
monkey-nut — a walnut — a small fig, having detected the side from which
the profuse haemorrhage was issuing by means of cystoscopy.

Treatment of the Hematuria. — Instrumental. — It is unwise to sound

KIDNEY, SUKGICAL AFFECTIONS OF 83

any profuse symptomless hematuria. Nor is it good practice to wash out
the bladder unless clot retention necessitates this procedure. Judicious
investigation of those cases without renal tumour consists in administering
Contrexevillo water until the urine is blood free, and then examining with
the cystoscope with the bladder full of clear urine. This determines the
absenco of any vesical cause of the haemorrhage. The next step consists in
recystoscoping during an attack of haemorrhage ; the origin of the blood is
thus detected by watching the ureteric efflux. The surgeon should at once
proceed to explore and remove the kidney which is bleeding. Nephrotomy
may become necessary in a few cases merely to relieve the agonising pain
due to tension of a rapidly growing hemorrhagic neoplasm. The relief of
the incision into the mass is great, but rapid death (seven days) ensues from
septicity.

Drugs. — It is better to avoid drugs which tend to arrest haemorrhage by
increasing the clotting power of the blood, for this generally leads to aggra-
vation of the distress by inducing clot colic or clot retention. Hot Con-
trexeville water, taken fasting, or a large dose of potash, is worthy of a
trial. It is always to be borne in mind that if the case is inoperative gentle
haemorrhage relieves pain and lessens the term of life.

When pain is a marked feature reliance should be placed upon opiates,
aud no anxiety need be felt about their action on the opposite kidney.

LITERATURE. — Grawitz. Archivf. Jclin. CMr. xxx. 1884. — Morris. Surgical Diseases
oftheKidney. 1885.— Kblynack: RenalGrowths. 1898. — Ltjbarsch. Virchow's Archiv, 1894,
B. cxxxv. — Osler. Principles and Practice of Medicine. 1898. — Lebert. Traitd des maladies
cancereuses. 1851. — Guilleman. Gaz. liebd. de mid. 1891. — Barth. Deutsche tried. Wochen-
schr. 1892. — Schede. Meine Erfahrungen iiber Nierenextirpation. 1889. — Israel. Erfalir-
ungen liber Nierenchirurgie. 1894. — Newman. Renal Cases. 1899.

Actinomycosis of the Kidney

Actinomycosis may invade the kidney under two conditions.

(1) The Metastatic Form. — This resembles pyaemia in its acute fever,
rigors, and secondary abscesses. When a primary lesion is present it is
usually about the face or mouth.

(2) The Consecutive Form. — This consists in an extension from the
intestinal canal, usually the csecum or appendix (Hinglass) ; 18 in 40 cases
of abdominal actinomycosis affect the caecum or appendix (Grill).

In the first variety the deposit is in the kidney substance, and will
probably remain unrecognised, in the second a perinephritic abscess of very
chronic type is formed. It is also said to occur as a primary condition
(Fischer). The condition is very rare indeed, and the kidney is less liable
to invasion than the lower urinary tract (Euhrah).

Diagnosis. — The special characteristics of actinomycosis are its very
chronic course, great infiltration, marked tendency to invade the skin and
form sinuses, with a peculiar red-violet colour of the integument, and the
discharge of pus containing " sulphur granules."

The condition most resembling actinomycosis is tubercular inflammation,
but the above characteristics may sufficiently differentiate it.

In 75 per cent of cases some occupation in which constant contact with
straw or grain (coachman, farmer, field-labourer, miller) is followed by the
patient (Leith).

" Sulphur granules " may be found in the urine when the urinary tract
is invaded (Billroth).

Treatment {Medical). — Potassium iodide is a specific for the disease, the
results of continued administration being very satisfactory.

84 KIDNEY, SUBGICAL AFFECTIONS OF

Local. — Abscesses are opened and scraped and sinuses dressed.

LITERATURE.— Grill. Beitr. f. klin. Ghir. 1895.— Fischer. VolkmanrCs klin. Vortr.
Chirurgie, Nos. 54-84, p. 2153, 1885. — Ruhrah. Annals of Surgery, 1899, p. 417. — Leith,
quoted by Ruhrah. — Hinglass. These de Lyon, 1897.

The Ureter

The ureter extends from the renal pelvis to the bladder, running in a
kind of lymph-space between the laminae of the subperitoneal tissue. Its
average length is twelve inches, and diameter when distended a sixth of an
inch. It is conveniently divided into abdominal pelvic and vesical portions.
The abdominal portion lies on the psoas, and genito-crural nerve, and under
the peritoneum. On the right side it has the inferior vena cava almost in
contact with it internally, and on the left the aorta internally.

The pelvic portion crosses the sacro-iliac synchondrosis, the obturator
internus, and then turns below the psoas to enter the bladder.

In this latter position in the male it is crossed superiorly and internally by
the vas deferens, and lies under cover of the free extremity of the vesicula
seminalis, separated from its fellow by a distance of an inch and a half. In
the female it runs parallel with, and four to six lines from the cervix uteri
— behind the uterine artery ; finally crossing the upper third of the
vagina to reach the vesico-vaginal interspace, and pierce the bladder opposite
the middle of the vagina (Anderson).

1. Injury. — Eupture of the ureter from violence without an external
wound is exceedingly rare, and the symptoms it gives rise to are not
characteristic.

After blows on the abdomen or loin, or crushes, the symptoms of
damage to other organs will probably claim attention, and the ureteric
injury may pass unnoticed. Pain and tenderness on pressure in the line
of the ureter are the only symptoms referable to the ureter. At first
hsematuria may occur, or it may be entirely wanting. It may be marked
or slight. Neither does the fact of it being absent after a severe injury to
the loin show that the ureter has been torn across. The first reliable
sign is the appearance of a swelling in the loin of a rounded or oval contour
some time after the accident. It is formed by retroperitoneal accumula-
tion of urine, for the serous membrane is unlikely to be ruptured coin-
cidently.

If a rigor now occurs, suppuration may be presumed to have taken place
in the sac, and the case may run an acute course with fatal issue, or may
gradually approach the surface as an abscess, and finally discharge, leaving
a urinary sinus. Suppuration does not always result, however, and a cica-
trix may form in the ureter which narrows or entirely obliterates the
lumen of the tube. Under these circumstances a hydro- or a pyonephrotic
swelling is likely to result, but in some cases complete atrophy of the
kidney has been demonstrated.

Months or even years may elapse before the dilated kidney is dis-
covered, and at this distance the original injury is apt to be overlooked.
If the peritoneum be ruptured at the time of accident, peritonitis rapidly
leads to a fatal result.

Treatment. — Operative interference should be advised when from the
appearance of a swelling the diagnosis of ruptured ureter becomes probable.
It will usually be limited to incision and drainage. Afterwards an attempt
may be made to restore the calibre of the ureter.

LITERATURE. — Cabot. Amer. Journ. of Med. Science, 1892. — Fenger. Trans. Amer.
Surg. Assoc, vol. sii. 1894. — Van Hook. Jour. Am. Med. Assoc. 1893. — Page. Ann. Surg.

KIDNEY, SUKGICAL AFFECTIONS OF 85

St Bonis, May 1894. — Morris. Clin. Jour. Aug. 1894.— Idem. Harveian Lectures, 1898. —
PATON. Brit. Med. Joum. Jan. 13, 1900. — KutJOEK. Berl. klin. Wochcnschr. 1899, xxxvi.
181.

2. Inflammation and Dilatation. — When the back pressure of prostatic
or other urethral obstruction begins to affect the ureter, the only symptom
which may evidence the fact is pain before micturition and relieved by the
act. The pain corresponds to a point internal to the mid-Poupart line,
and on a line with the anterior superior iliac spine; sometimes the external
abdominal ring is the seat of pain. By the use of the cystoscope further
evidence may be obtained, for the mouth of the ureter usually shows signs
of dilatation.

Inflammation of the ureter (ureteritis) either ascends from the bladder
or descends from the renal pelvis. The patient complains of intermittent
pain along the course of the ureter, and that tube may sometimes be felt as
a tender cord on abdominal, vaginal, or rectal palpation.

No treatment is specially directed towards the ureteric affection, for it
is the same as that of pyelitis.

LITERATURE.— Fournier. These de Paris, 1885-6.— Halle. " Ureteritis et pyelitis, "
These de Paris, 1887.— Israel. Berl. klin. TFochenschr. 1899, xxxvi. 201. — Kelly. Jour.
Am. Med. Ass. Chicago, 1900, xxxiv. 515. — Fenger. "Diseases of the Ureter" in Amer.
Text-book of Genito-Urinary Disease, etc. Bangs and Hardaway, 1898. — Casper. Berl. klin.
Jf'ochenschr. 1898, xxxv. and 1899, xxxvi.

Stone in the Ureter

The majority of renal calculi either remain in the renal pelvis or pass
quickly through the ureter and drop into the bladder ; in some cases, how-
ever, the stone, although small enough to enter the ureter, is too large safely
to traverse the normal tube, or is arrested by some abnormal stricture or
valve.

Clinical Notes. — 1. On the Ureter in Relation to Stone. — There are three
narrow points in the normal ureter at which a stone is likely to be arrested.

(1) At its upper end or just below this (4-7 cm.).

(2) At the point where it crosses the iliac artery and rounds the brim
of the pelvis. (Narrowed in three out of five cases, Kelly.)

(3) Where the tube passes into the thick muscular wall of the bladder.
At any one of these points a " migratory " calculus may be stopped; most

often, however, the tube is blocked at the upper end (66 per cent, Morris),
less frequently at the lower end (17"8 per cent), or at the pelvic brim (12-5
per cent). It is supposed that in many cases calculi have already passed
along the ureter, and the damage caused by their rough crystalline surface
has been followed by scarring and constriction of the tube, and a stone
small enough to pass the natural danger points is arrested at the stricture.
The calculus may completely block the ureter, but it may only partially
obstruct the passage, and at the level of the stone the wall becomes pouched
to form a bed for it. The calculus may be found lying loose within the
ureteric pouch, and may by further deposit increase in size. I have gener-
ally found " acid " stones in these pouches. The phosphatic calculi tends
to fill and block the ureteric channel.

At the lower end of the ureter a calculus when impacted may slightly
bulge the bladder wall, but it sometimes projects through the ureteric
opening into the vesical cavity, and can be seen with the cystoscope.

2. On the Stone. — Usually a single stone, rounded, ovoid, or oblong in
shape and of small size, is present ; sometimes several are found. A con-
siderable size may be reached by fresh deposits occurring, and a long sinuous

86 KIDNEY, SUKGICAL AFFECTIONS OF

calculus sometimes results. Stones projecting from the lower ureteric
orifice often attain a remarkable shape, with a vesical cap, narrow neck,
and thicker ureteric stem (Bishop's, Zuckerkandl's cases). At the upper
end of the ureter they often resemble a nail with the head lying in the
pelvis (Albarran).

3. On the Examination of the Ureter. — The means which are at the
disposal of the practitioner of investigating the condition of the ureter are
few, but simple and should never be neglected.

Palpation of the abdominal wall in the line of the ureter — a vertical line
from the junction of the inner and middle thirds of Poupart's ligament —
should be systematically carried out. The spot where it crosses the pelvic
brim, at the intersection of a horizontal line between the anterior iliac
spines with a vertical one from the pubic spine (Tourneur), sometimes
shows a point of special tenderness. If the abdominal walls are thin and
the ureter enlarged the tube itself is stated by Fenger to be recognisable.
I .can only state that it is extremely difficult to find the ureter unless it is
tuberculous even when the finger is introduced through a parietal wound.

Pain and intense desire to micturate are evoked by pressure on a
diseased ureter. Kelly says, " It is not sufficiently appreciated that a very
important section of the ureter may be explored from the rectum by the
finger when the patient is in the knee-elbow position, in either sex as high
as the iliac artery, and I have on several occasions detected stone in the
ureter by this method. A stone may be overlooked by not carrying the
finger as high as the perineum will permit. In the female the ureter can
be palpated by vaginal examination, from its vesical termination as far as
the broad ligament, and can be rolled beneath the finger."

Symptomatology. — A stone may lie in the ureter without completely
blocking it, and give rise to no symptoms (Albarran), but in the majority of
patients in whom a calculus becomes arrested in the ureter, there is a history
of previous attacks of " renal " colic and other symptoms of renal stone, so
that little doubt exists of the calculous nature of the case.

Instead of a sudden relief from an attack of renal colic indicative of the
" migrating " stone dropping into the bladder or falling back into the renal
pelvis, the suffering of the patient whose calculus remains in the ureter only
slowly declines, and the clinical course of the case will now be either acute
or chronic, depending on the completeness of the obstruction and the state
of the other kidney.

The more acute course is that of calculous anuria, already discussed,
and it only remains to consider the chronic cases where the block in the
ureter is incomplete and the fellow-gland sufficiently healthy to maintain
the secretion.

These cases differ according to the situation of the calculus. If at the
middle or upper part of the ureter there is nothing which will serve to
distinguish them before operation from calculus in the renal pelvis or
calyces.

The initial colic subsides gradually, and often recurs from time to time
with less intensity than on the first occasion. The pain is sometimes
referred to one particular spot in the line of the ureter, and may be fixed
and constant between the attacks of " renal " colic (Le Dentu), and in some
cases a tender ureter may be discovered on palpation, which, if constant,
has some localising value (White and Martin). In exceptional cases dilata-
tion of the ureter above the impacted stone has been felt. In one case a
ureteric calculus was recognised through the abdominal wall (Fenger).

These signs will, in the majority of cases, be absent, and it is only after

KIDNEY, SURGICAL AFFECTIONS OF 87

months or years, when the kidney is explored for stone or a swelling appears
with the characters of a hydronephrosis or a pyonephrosis, and is exposed
by the surgeon, that the situation of the calculus is ascertained.

A stone situated at the lower end of the ureter may give rise to symptoms
in no way differing from one in the higher parts of the tube, but many of
the cases are sufficiently distinct to lead to a certain diagnosis.

In a case where signs of renal calculus were present, constant and marked
pain in the lower part of the abdomen has drawn attention to the situation
of a stone in the lower ureter, but more striking are the cases where symptoms
have pointed to stone in the bladder.

There is marked and frequent desire to micturate, with straining and
the discharge of small quantities of urine, pain at the end of the act often
referred along the urethra or to the glans penis. Some hematuria may be
observed, often recurrent, and the urine may contain besides red cells and
leucocytes, oxalate or uric acid crystals.

The effect of movement and vibration is not, however, so marked as is
usually the case in vesical stone, for walking and driving may have little
effect in increasing the symptoms.

The effect of posture is sometimes striking, for the suffering may be
more intense on standing or sitting, especially with an empty bladder
(Zuckerkandl's case), or the patient may be unable to lie on the affected
side (Bishop and Fenwick's cases). On passing a sound in these cases a
sensation of a " soft membrane " covering some hard substance may be
detected (Morris's case), or the metal may ring clearly on a projecting part
of the stone, and the fixity and constant position will be noticed.

On rectal examination a hard mass is usually felt lying in close relation
to the bladder wall and tender to the touch, and on vaginal examination a
similar body may be felt in the region of the broad ligament. In some cases
the finger in the rectum has detected a calculus where none was felt from
the vagina. The cystoscope in one case showed the lower end of the ureter
to be proptosed and covered with a small villus tuft (Fenwick).

Diagnosis. — Mimetic conditions.

Benal Lithiasis. — A calculus lying in the middle or upper portion of
the ureter cannot be differentiated from one in the renal pelvis or calyces.

Vesical Calculus. — A stone in the lower end of the ureter may closely
resemble vesical calculus. The means of diagnosis are by rectal or vaginal
examination of the ureter and the information gained by the sound or
cystoscope.

Primary Tubercle in the Vesicula Seminalis. — This must be guarded
against by a careful analysis of the urine for bacillus and by rectal
examination.

Ovarian and Tubal Disease. — Long-continued pelvic pain with radiations
and increase during the menstrual congestion, together with a tender swell-
ing in one fornix on vaginal examination, due to calculus impacted in the
lower ureter, has led to removal of the ovaries and appendages from erroneous
diagnosis.

A careful examination of the ureter by vaginal examination and of the
ureteric orifice by cystoscopy, and attention to the history, should prevent
such mistakes.

Additional Aids to Diagnosis. — In some cases a radiograph has been taken
of the pelvis, and evidence of the extravesical site of the calculus has been
obtained (Leonard, Zuckerkandl).

The cystoscope and the catheterising cystoscope may give useful informa-
tion in a calculus situated low down.

88 KIDNEY, SUKGICAL AFFECTIONS OF

The passage of a wax-tipped bougie along the ureter in women may
on withdrawal give the evidence of scratches produced by the calculus
(Kelly).

Advice to Patients about Operative Treatment. — The only treatment of any
avail is removal, and this should be urged as soon as possible before the
kidney has become deteriorated by blockage and ascending inflammatory
changes. One danger which is not sufficiently emphasised is perforation of
the ureter above the calculous block and consequent extravasation. I operated
on such a case lately, the calculus being four inches below the kidney and
the perforation was one inch from the pelvic orifice of the ureter.

It should, I submit, be a general operative rule that if the stone be

found in the upper third of the ureter, the ordinary lumbar incision should

be employed ; if at the pelvic brim, the common iliac artery incision suffices ;

if below the pelvic brim, the incision should be perineal or vaginal. Several

cases have lately been recorded in which the abdominal incision for tying the

common iliac artery has been followed, and, the peritoneum having been

raised, the lower end of the ureter has been reached extraperitoneally.

There is no doubt that this incision is of value when one has to remove

the ureter in its entire length, or to extract stones which have become

impacted in that canal at the pelvic brim or about that level ; but I question

if it is not unnecessarily severe when the stone has become lodged below

the pelvic brim.

LITERATURE. — Kelly. Operative Gynaecology, 1898, and Jour. Amer. Med. Assoc.
March 3, 1900. — Halle-. Gaz. des Mpitaux, No. 112, 1887. — Tanquary, quoted by Van
Hook, Jour. Amer. Ifed. Assoc. 1893. — Tuffier. TraiUde Chir. vol. vii. 1892.— Tourneur.
These de Paris. 1886. — Le Dentit. Affections des reins. 1889. — Cabot. Am. Jour. Med.
Sc. vol. i. 1892. — Lane. Lancet, 1890, vol. ii. p. 967. — Fenger, in Amer. Text-hook of
Genito - Urinary Bis. Bangs and Hardaway. — Leonard. Ann. of Surgery, 1900, p. 167.
— Albarran. Maladies du rein, and Ann. gen. urin. 1895. — Zuckerkandl. Wiener Tclin.
Wochenschr. 1900, p. 8.— Stanmore Bishop. Ed. Med. Jour. July 1899.— Morris.
Hunterian Lectures, 1898, and Amer. Jour. Med. Sc. 1884.' — Jacobson. Operations of Surgery.
1897, p. 747.— White and Martin. Genito- Urinary Surgery, 1897.— Sutherland. Glas.
Med. Journ. 1898. — Israel. Berl. Tclin. Wochenschr. 1899. — Tuffier. Ann. Mai. des
Org. Gen. Urinar. Oct. 1897. — Desquin. "Calcul de uretere extrait par la laparotomie,"
Soc. Beige de Ghirurg., mai 1899. — Frever. Lancet, July 1899. — Sunderland. Medical
Bress and Circular, May 30, 1900. — Hurry Fen wick. Edinburgh Medical Journal,
March 1898.

Operative Procedures

Methods of Exposing the Kidney. — The patient lies upon the sound side
with a hard pillow beneath the loin. Many incisions have at various times
been suggested and practised in laying bare the kidney. There are two
chief methods, the lumbar or extraperitoneal, and the abdominal or trans-
peritoneal. "Without entering into the discussion on the merits of these
methods it may be said that the latter is now almost universally confined
to those cases where a tumour of such size is present that removal by the
loin becomes impracticable from want of space, and that such include only
large renal growths. The technique is that of other abdominal operations,
the incision being made through the linea semilunaris, or in such manner
as to give freest access.

The lumbar incision most usually adopted is an oblique one from the
angle between the last rib and the erector spinas muscle, or a little below
this and passing downwards and forwards towards the anterior superior iliac
spine. The length of this incision varies with the extent of the operation.
In an exploration of the kidney, or a nephrolithotomy, a small incision will
often suffice ; for the operation of nephrectomy more room will be required,
and for the thorough examination of the ureter or its removal the incision

KIDNEY, SUEGICAL AFFECTIONS OF 89

should be prolonged down and forward, passing about an inch in front of
1,1 ic anterior superior iliac spine, and continued if necessary as far as the
internal abdominal ring (Morris). In dividing the muscles the quadratus
Lumborum need not be incised. The further steps are described under the
different operations.

With the object of avoiding the danger of a lumbar hernia Mayo Eobson
has applied M'Burney's method of treating the abdominal wall by incising
the muscles in the direction of their fibres, and freely retracting them.
The space for manipulation is of course curtailed, but often suffices for
exploration or nephrolithotomy, and its advantages are great.

Nephropexy. — Since Hahn in 1881 introduced the operation of fixing a
wandering kidney many methods have been tried ; some have been found
trustworthy. The operation on a floating kidney differs from that on a
movable one, in the fact that the peritoneal cavity must be opened, but in
all other points the procedure is similar.

The kidney is approached by the usual lumbar incision, and its fatty
capsule exposed. The hand of an assistant guides the organ into its natural
position, and the perinephritic fat, which is often atrophied, sometimes even
wanting, is incised and torn through until the capsule proper of the kidney
is laid bare.

Albarran considers it of great importance to remove as much fat as
possible, so as to allow the kidney to lie upon the muscular wall, and in
this manoeuvre the fingers or forceps are used. The kidney is now very
carefully examined and palpated to ascertain whether other conditions,
such as stone, tubercle, etc., are present.

Sutures, usually three in number, are then passed, at intervals of about
half an inch, through the kidney substance, and on each side include the
fatty capsule, the transversalis fascia and the muscles. These are tied
firmly, and the superficial wound closed with or without drainage.

The patient is kept recumbent for three or four weeks, and thereafter
wears a belt for some months.

Some authors consider it necessary to lay bare an area of kidney
substance by splitting the capsule and turning back flaps, or by removing
a portion of it (Tuffier, Jacobson, Kocher). Thick catgut may be used as
suture material, but this is rapidly absorbed, and the part of the suture
within the kidney substance is said to be more quickly destroyed than that
without (Newman). Kangaroo tendon has also been used, but sterilised
silk sutures are perhaps the best of any. Vulliet uses a strand of the
erector spinse tendon torn from its upper attachment, but remaining
attached below. This he passes through the muscles into the lumbar
wound, beneath the kidney capsule, and back through the muscles again.

The method is ingenious, although somewhat complicated, and is at present
on probation. The living suture is said to have sloughed out, but this is an
unusual occurrence.

To ensure fixation of the kidney, Guyon, Albarran, and others pass the
upper suture round the lowest rib, while others promote granulation and
subsequent increased cicatrisation of the wound by inserting a large drainage-
tube or by packing with gauze.

Nephrolithotomy. — In this operation the kidney is exposed by the oblique
lumbar incision, and the finger introduced into the wound is passed at once
to the pelvis, which is carefully palpated for stone. No concretion being
discovered the anterior and then the posterior surface of the kidney is
examined.

Should no stone be revealed the lumbar incision is now extended

90 KIDNEY, SUKGICAL AFFECTIONS OF

downwards and forwards, and the kidney freed from its surroundings and
drawn out into the wound, or merely into the wound if the pedicle is
short and inelastic. A further careful palpation between the finger and
thumb may now discover a spot of increased resistance, but failing this
the organ is incised along its convex border, the left finger and thumb of the
surgeon meanwhile controlling the bleeding by pressure on the renal pedicle.
The finger is now introduced through the kidney substance into the pelvis,
and a further search if necessary is made by introducing a small metal
sound, the upper and lower calyces receiving especial attention.

No stone having been revealed by these measures, a bougie is passed
down the ureter to ascertain its permeability ; nor should this precaution be
neglected after the discovery and removal of a renal or pelvic stone.

The stone is removed, if possible, entire by means of the forefinger, aided,
if need be, by fine forceps or scoop, but sometimes it is necessary to break up
a large mass before it can be delivered from the renal wound.

A stone after being removed from the pelvis should always be examined
very carefully for chipped surfaces, for there is a very real danger of leaving
a portion of a branched calculus behind, and for the same reason it is well
to flush out the pelvis with a copious stream of aseptic solution.

After removal of the concretion the kidney wound is closed by catgut
sutures, and the lumbar wound closed except for a couple of drains retained
in place for a few days.

Some authorities prefer to open the pelvis (pyelotomy) rather than cut
through the kidney substance. The advantages claimed are the rapidity
and ease of the operation, and that the kidney is spared the after-effects of
an incision through its parenchyma. For small stones in the pelvis dis-
covered immediately by the finger the method is undoubtedly of service, but
there is much less space for manipulation and greater difficulty in removing
a large calculus, and especially if it is branched, and there is a greater
probability of a sinus resulting (Albarran). Morris and Israel recommend
the closure of the pelvic wound by Lembert's sutures, by which means the
danger of a persisting sinus is lessened ; the application of sutures, however,
is often very difficult (Gliterbock).

The patient is usually able to be up three weeks after the operation.

Nephrotomy consists in incising a kidney which has been more or less
destroyed by suppuration or back pressure, or both, or which is the seat of
a cyst.

The incision in no way differs from that described in other kidney
operations.

In cutting on the kidney the tissues are likely to be oedematous and
excessively vascular, and the perinephritic fat infiltrated and often increased
in amount, while sometimes pus is discovered surrounding the kidney.

On . reaching the distended kidney an incision is made into it and the
finger introduced. A calculus should be searched for in cases of hydro- and
pyonephrosis, cheesy material removed in tubercular kidney, and the mortar-
like phosphatic material sometimes found in dilated kidneys scraped and
washed away. A large double drain should be placed in the kidney sac.

Sometimes it is possible to stitch up the kidney wound, even after opera-
tion upon a suppurating kidney, but in most cases this is undesirable.

Nephrectomy. — A kidney may be removed by an abdominal or a lumbar
incision, the relative values of which have already been noticed.

The kidney having been exposed, adhesions to the surrounding parts
should be separated. This is often exceedingly difficult, and requires great
care and gentleness.

KIDNEY, SUEGICAL AFFECTIONS OF 91

The pedicle next claims attention. It should be isolated as far as
possible. Sometimes, however, dense adhesions surround the vessels and may
unite the kidney by a cicatricial mass to the vena cava or aorta, and make
this part of the operation difficult and dangerous. The kidney is now
raised and steadied by an assistant while the ureter is separated from the
rest of the pedicle. Through the vascular part of the pedicle a stout silk
ligature is now passed by means of an aneurysm needle, tension on the
pedicle is then relaxed, and the ligature firmly tied.

The ureter is clamped with forceps, and the whole pedicle cut through
by short cuts of the scissors, and at a sufficient distance from the ligature to
avoid the danger of its slipping. The ureter is now examined ; if healthy
it is dropped back into the abdomen after being closed by ligature.
Thornton and Albarran have recommended fixing it in the lower part of
the wound, but this is an unnecessary precaution. If inflamed or the seat
of tubercular infection some attempt may be made with antiseptics or the
cautery to remove at least a part of the disease, and often it gives no further
trouble. The most radical method of treatment is to follow it down, and
to isolate and remove it either at the time of the nephrectomy or at a later
date.

The wound is then closed, and the cavity left by removal of the kidney
is drained for varying periods according to the character of the case.

Subcapsular nephrectomy was introduced by Oilier. It is most useful
when an enlarged kidney is firmly bound to surrounding structures by
adhesions, but should never be used in dealing with malignant tumours.

The capsule proper of the kidney is incised and peeled off, and the
pedicle clamped. The kidney is now removed and a silk ligature is applied
to the pedicle.

If the pedicle is short and thick, clamps may be used. They should be
allowed to remain in situ for at least forty-eight hours.

The objection to the operation is the rigidity of the walls of the cavity,
which delays healing.

Partial nephrectomy or resection of the kidney has been performed by
Czerny, Turner, Morris, and others for localised tumours, abscesses, and cysts,
and for injury. The operation has not as yet been widely adopted, but is a
sign of the present tendency to conservatism in renal surgery.

Operations on the Ureter

Operations on the ureter usually follow an exploration of the kidney,
and the abdominal portion of the tube is exposed by extending the lumbar
incision downwards and forwards and raising the peritoneum.

A stone situated in the ureter may sometimes be pushed up by the
fingers and extracted through the renal or pelvic wound ; sometimes, how-
ever, the stone is so firmly impacted that this is impossible, and an incision
in the long axis of the ureteral wall (ureterotomy) directly on to the
calculus is necessary for its removal. The ureteric wound should, if
possible, be sutured, but when the stone is directly cut upon, the damage
already produced by pressure may render this inadvisable (Morris).

In all cases, whether sutures be applied or not, drainage of the wound
should be provided for in case of retroperitoneal leakage. In the case of a
stone impacted in the pelvic portion of the ureter the same method may be
employed, but in the female an incision through the vaginal wall is best in
stones impacted low down, and in the male the stone can be removed through
the perineum (Fenwick).

KNEE-JOINT, DISEASES OF

Strictures of the ureter are now treated in the same way as pyloric
stenosis by a longitudinal incision united transversely (Heineke-Mikulicz
method), or the contracted portion of the tube may be resected, and the
lumen re-established by one of the various methods of " uretero-ureteric
anastomosis." Ureterectomy consists in partial or even total removal of a
diseased ureter. It has been employed in tubercular and also in suppura-
tive ureteritis, being performed either at the same time as nephrectomy
or at a later date.

Knee-Jerk. See Spinal Cord.

Knee- Joint. — This subject is considered in two articles —
1. Diseases of. 2. Injuries of.

Diseases in the Region of the Knee- Joint

Anatom

ical Considerations

Deformed Attitudes in Disease

op Knee ....

Classification of Diseases —

Tuberculosis .

2.
3.

Syphilis. See Joints .
Pyogenic Diseases {includ-
ing Gonorrhoea and

Osteomyelitis in Region
of Knee) .
Rheumatism. See Joints

107

Arthritis deformans

109

Uosmophylia (bleeder's
knee)

110

Charcot's Disease .

110

8.
9.

Hysterical Knee
Loose Bodies .

110
110

10.

Contracture and Anky-
losis— under different
diseases

110

11.

Pathological Dislocation

110

14.

19.

110
111

111

112

113

112

114

Congenital Dislocation —
of knee .
of patella
Diseases of Superior Ti-
biofibular Joint
Diseases of the Bursas

around the Knee
Ganglia in the Region of
the Knee .
16. Tumours in the Region of
the Knee. Hydatid
Cysts
Paralysis of Muscles act-
ing on Knee .
Paralytic Contracture
Paralytic genu recur-
vatum .
Other deformities in Re-
gion of Knee. See
Deformities, vol. ii.
Operations on the Knee —
Arthrotomy, Arthrec-
tomy, Excision. Under
Tuberculosis, p. 104.

The knee is probably more often the seat of disease than any other joint in
the body, probably because of its size and the great extent of its synovial
membrane, and because it is more exposed to injury and to cold, either of
which is capable of favouring the action of disease -producing agencies.
Some of the diseases met with in the knee are rarely seen in any other
articulation, while if we pass in review the different diseases that involve
joints and note their seats of election, it is the knee in almost every instance
that is most prone to be attacked. Although the joint is to a large extent
subcutaneous, and therefore lends itself to direct examination, the number
and variety of morbid conditions to which it is liable may render their
clinical recognition a matter of difficulty and sometimes of uncertainty.

Anatomical Considerations

The synovicd membrane extends upwards above the patella and beneath the
quadriceps extensor in the shape of a pouch or cul de sac; it is rendered very

KNEE-JOINT, DISEASES OF 93

distinct when the joint is distended with fluid, or when the synovial membrane is
the seat of the diffuse thickening which so frequently attends tuberculous disease.
The precise limit of this upper pouch varies with the development of the sub-
crural bursa and with the size of the communication between it and the bursa.
Sometimes the communication is so wide that the cavities are practically con-
tinuous with one another ; sometimes it is very narrow, and will scarcely admit the
tip of the little finger ; in young children the communication is either very narrow
or is not developed. The reflection of the synovial membrane is a little higher in
the extended than in the flexed position of the limb ; it is generally stated as being
an inch or more above the upper margin of the patella, but it may be as high as
three inches or more. The capacity for distension exhibited by the upper pouch
of the joint in the extended position of the limb is partly due to the capsular liga-
ment above the patella being replaced by the quadriceps extensor, which is of
course relaxed and flaccid in the attitude of complete extension. When there is
only a small amount of fluid in the joint it is most easily recognised if the patient
stands with his feet together and the trunk bent forwards at the hip joints ; the
complete relaxation of the quadriceps allows the fluid to bulge above and on either
side of the patella, where its presence is readily detected ; if the healthy joint of
the other limb is examined in the same attitude there should be no likelihood of
making a mistake.

The great extent of the synovial membrane of the knee is concerned in the rapidity
with which effusion may take place, and it is also concerned with the severity of the
poisoning from the absorption of toxines when the joint has been infected with
pyogenic organisms.

The great development of the villous processes and fringes of the synovial mem-
brane is responsible for the frequency with which, under the influence of disease,
they may take on an exaggerated growth, and give rise to the pedunculated and
other forms of loose body which constitute a prominent feature in many of the
chronic diseases to which the knee is liable.

The communications bettveen the synovial cavity and the surrounding btirsce are
of importance in relation to hydrops and to the spread of infective conditions.
That with the subcrural bursa has already been referred to. In about 50 per cent
of bodies there is a communication with the bursa between the semimembranosus
and the inner head of the gastrocnemius, which latter may form a considerable
swelling in the ham in cases of hydrops. There is sometimes a communication
between the knee and the superior tibio-fibular articulation, usually through the
mediation of the popliteal bursa.

The epiphysial junctions in the region of the knee are chiefly responsible for the
growth in length of the lower extremity ; they are later (21 to 25 years) in uniting
with their respective shafts than those at the hip or ankle. If their functions are
interfered with, whether by injury, or disease, or operation, serious shortening of
the limb may result. In relation to disease, it is of great importance to bear in
mind that infective lesions at the epiphysial junctions are less likely to spread to
the joint than is the case with similar lesions at the hip, shoulder, or elbow : in
the knee the epiphysial cartilages reach the surface beyond the limits of the
synovial cavity.

Deformed Attitudes in Knee-joint Disease

The attitude assumed in many forms of knee-joint disease, and especially in
tuberculosis, is that of flexion, with or without external rotation of the leg and foot.
The occurrence of flexion is explained by its being the natural attitude of the joint
at rest, and by affording most ease and comfort to the patient. Whether or not
the preponderating influence of the flexor muscles can inaugurate flexion is
doubtful; it is certain, however, that when the joint has become flexed, however
slightly, the involuntary effort of the patient to fix the joint is chiefly exercised
by the flexor muscles. If the patient is able to walk on the limb the weight of
the body is a powerful factor in increasing an already existing flexion. The
greater capacity of the joint sac in the flexed position may be an occasional factor
in determining this attitude ; it is commonly observed, in cases in which a large
amount of fluid is thrown out rapidly, that the patient is unable to extend the
limb, whereas in chronic effusions, such as the hydrops of arthritis deformans or of
Charcot's disease, the joint may contain an enormous amount of fluid and yet be
completely extended without discomfort, because the capsule has had time to yield
and stretch. The external rotation of the leg is supposed to be associated with

KNEE-JOINT, DISEASES OF

the contraction of the biceps muscle; this may or may not be the case; it is
certain that the outward rotation is most marked in cases in which the patient
has been confined to bed.

One of the most characteristic deformities of the knee is that associated with
backward displacement of the tibia ; it is especially met with in neglected cases of
chronic and especially tuberculous disease, where the patient has been allowed to
walk and bear weight on the limb when it is already flexed at the knee. This
mechanical explanation of the occurrence of backward displacement is in our
opinion a more reasonable one than others which have been suggested. _ By many
it is ascribed to the traction of the hamstring muscles and the cicatricial contrac-
tion of the capsular ligament and other structures in the ham, the displacement
being rendered possible by the softening and yielding of the crucial and other
controlling ligaments ; it has also been suggested, inasmuch as the backward dis-
placement is invariably associated with flexion, and that it is only observed in
patients before the skeleton has attained maturity, that the growth of the femur,
in the flexed position of the limb, may result in its projection beyond the tibia. _

There is still another deformed attitude met with in knee-joint disease, viz.
a certain degree of genu valgum or abdtcction of the leg ; it is commonly associated
with slight flexion, and is chiefly met with in patients who have borne weight on the
limb in walking ; the valgum is also associated with slight outward displacement
of the patella on to the external condyle, with prominence and apparent enlarge-
ment of the internal condyle, with depression of the pelvis on the diseased side,
and apparent lengthening of the limb.

All of the above deformed attitudes are especially met with in tuberculous
disease of the knee-joint, and an accurate knowledge of them is of great import-
ance in the treatment of the disease in question.

Tuberculous Affections of the Knee

General Facts . . . .93
Pathological Anatomy . . 93
Clinical Types —

1. Hydrops .... 95

2. Papillary or Nodular Tu-

bercle of the Synovial Mem-
brane . . . .96

3. Cold Abscess or Emp>yema . 97

4. Diffuse Disease of Synovial

Membrane —

Synovial fungus. White

swelling . . .97

5. Primary Disease in the

Bones .... 98

The Formation of Abscess
Diagnosis .
Prognosis .
Treatment —
Conservative
Operative

Indications fot
Arthrectomy
Excision
Amputation
Treatment of Deformities
folloiving Disease of Knee .

101

102
103
103
104
105
106

106

In patients of all ages affected with tuberculous disease of bones and joints
the knee-joint is the second most frequent seat of disease. While especially
common in childhood and youth, it may be met with at any period of life,
and is not uncommon even in patients over fifty or sixty years of age. It is
less serious to life than the same disease in the spine, pelvis, or hip, chiefly
because it is much more amenable to treatment.

Pathological Anatomy.— The frequency with which the disease originates in
the synovial membrane and in the bones would appear to be about equal (351
synovial to 281 osseous, Konig). When the synovial membrane is the seat of
disease it exhibits a marked tendency to grow inwards over the articular surfaces ;
in the case of the femur this usually takes place from the lateral margins of the
condyles at the level of the lower margin of the patella, often shutting off the
suprapatellar pouch and resulting in fixation of the knee-cap. In the case of the
tibia and of the patella, the ingrowth takes place from the margins towards the
centre, diminishing the area of their articular surfaces. The ingrowth of the
synovial membrane may come to fill up the entire cavity of the joint or may divide
it up into compartments, e.g. one above the patella, and two below in relation to

KNEE-JOINT, DISEASES OF 95

each femoral condyle, and may succeed in shutting off a focus in the bone which
would otherwise have erupted into the joint. In addition to the tuberculous
thickening of the synovial membrane, the thickening and gelatinous transforma-
tion of the parasynovial tissues, and especially of the fat around the joint,
contribute in an important degree to that form of the disease which is known
clinically as " white swelling." The destructive changes in the synovial membrane
and in the articular cartilages, which result from the tuberculous infection, are
similar to those met with in other joints.

It is important to bear in mind that, when the infection is arrested and the
newly-formed granulation tissue is converted into fibrous tissue, this is often
attended with alterations in the joint of a more or less permanent character. The
suprapatellar pouch is often obliterated, the patella may be more or less fixed on
the condyles of the femur; the tibio- femoral articular surfaces may be fused
together by fibrous tissue or by bone, and the joint may be ankylosed in the
position in which it was maintained during the disease. In relation to the
question of relapse, it is important that the reparative process may be limited to
one or other portion of the joint, e.g. one condylar area, while the disease may
remain latent or may progress in other parts, and that by the formation of new
fibrous tissue, a focus in the bone may be shut off or encapsulated.

The rarer forms of synovial disease will be described under the clinical features.
The nature and seat of the bone lesions are subject to the same wide variations as
in other joints. Konig gives the following figures as to their relative frequency in
the different bones : in 281 cases the patella was affected in 33, the femur in 97,
the tibia in 107, and several bones in 48. Small, frequently multiple, granula-
tion foci may be found beneath the articular cartilage of the tibia, or along the
lateral margins of the femoral condyles, especially the internal. Caseating foci are
less often met with ; they may, however, attain a considerable size, so as to merit
the description of a caseous abscess, especially in the interior of the head of the
tibia. Foci of the sclerosed variety, resulting in sequestra, are comparatively
common ; the most characteristic examples are met with in the substance of one or
other condyle of the femur, and when they abut on the articular surface they
present the peculiar eburnation. Extensive caseation (tuberculous osteomyelitis)
of the marrow of an entire epiphysis is exceptional, but when present may extend
into the adjacent diaphysis. Primary foci in the patella may erupt externally,
more often they give rise to disease in the knee-joint.

In young children the frequency of severe bone lesions, such as sequestra, is
considerably above the average ; they are more often located in the femur than in
the tibia, but instead, as in the adult, of infecting the joint, they commonly erupt
extra - articularly, e.g. into the popliteal space or on the lateral aspects of the
condyles.

Clinical Types of Tuberculous Disease of the Knee

1. Hydrops tuberculosis is the name given to that type in which the
outstanding feature is the accumulation of fluid within the joint. It is
analogous to the ascitic type of peritoneal tuberculosis, and it is the chief
representative of the " chronic simple synovitis " of the older authors. It is
most often met with in the knee of young adults, but may occur at any age.
Inasmuch as it frequently terminates in recovery with a useful joint, it may
be regarded as the least serious form of tuberculous joint disease ; this is
largely due to its origin from a purely synovial lesion ; foci in the bones are
exceptional, but they may be the cause of the hydrops in those cases where
the joint becomes suddenly distended with fluid.

In the serous form of hydrops the fluid accumulates gradually and
imperceptibly; the capsule is chiefly distended in its upper recess, the
patella is pushed forwards and floats ; there is no pain ; the functions of the
joint are fairly well preserved, as the movements are only hindered by the
distension of the capsule ; there may be some complaint of tiredness, but
the patient is usually able to walk in moderation without discomfort ;
prolonged distension of the capsular and other ligaments may cause a sense
of insecurity and instability ; the variation in the amount of fluid from

96 KNEE-JOINT, DISEASES OF

time to time is characteristic ; it subsides under rest and increases after
exercise.

In the fibrinous form of hydrops the joint also slowly fills with fluid,
but unless the capsule is tightly distended we are usually able to recognise
some thickening of the synovial membrane, especially along the line of its
reflection on to the femur. By displacing the fluid from one part of the sac
to another by means of the fingers, we may recognise a peculiar friction or
crepitation from the contact of floating masses of fibrin and melon-seed
bodies against one another ; this is best appreciated if the knee is rapidly
flexed and extended by the patient while it is grasped and compressed by
the fingers. If the fluid is evacuated, it is found to have suspended in it
fibrinous bodies, often of the melon-seed type, which are very apt to block
the canula. If the joint is opened a similar fibrinous material may be
found lining the synovial membrane, and it may be also covering certain
areas of the articular surfaces.

The diagnosis of tuberculous hydrops is to be made from that arising
from other causes, e.g. from injury, and especially repeated sprains of the
joint, from gonorrhoea, from arthritis deformans and Charcot's disease, from
the hydrops which may attend staphylococcus disease (e.g. Brodie's abscess)
in one of the adjacent bones, and lastly, from the hsemarthrosis met with in
bleeders. Given a patient, and especially a young adult, with water in the
knee, and having excluded injury, the probability is that it is due either to
tuberculosis or to gonorrhoea. The presence of melon seed or other fibrinous
bodies in the fluid is confirmatory of tuberculosis. The demonstration of
bacilli and the results of inoculation in animals are too uncertain to be of
any value.

The treatment will be considered with that of tuberculous disease of the
knee in general, but it may be pointed out in this place that the hydrops is
especially amenable to conservative treatment by rest, and by injections into
the joint of iodoform glycerine. In the fibrinous variety a large canula
must be used, otherwise it is liable to be blocked ; even then it may be
impossible to evacuate the contents of the joint; the choice will lie under
these conditions, between diluting the joint contents with saline solution
introduced by a syringe and washing out the joint before introducing the
iodoform, and making an incision into the upper pouch, squeezing out the
fluid and loose bodies, and injecting the iodoform by means of a rubber tube
attached to the nozzle of the syringe, the tube being gradually withdrawn
as the stitches closing the incision are tightened up.

As already indicated, the prognosis is favourable as regards cure of the
disease and recovery of a useful joint, but relapse is not uncommon, and
experience shows that neglect of the disease may be followed by a gradual
transition of the innocent hydrops into the graver types of synovial tuber-
culosis.-

2. Papillary or nodular tubercle of the synovial membrane maybe employed
as a clinical term to distinguish a group of conditions in which the dominant
feature is a fringy, papillary, polypoidal, or tumour-like growth from the
synovial membrane, sometimes localised and circumscribed, sometimes gener-
alised throughout the entire membrane. The conditions referred to are com-
paratively rare, but are usually attended with characteristic clinical features.
They are more often met with in male adults between the ages of 20 and 40.
The onset and progress of joint symptoms are extremely gradual ; the patient
complains of stiffness and swelling, chiefly after exertion, sometimes sub-
siding for weeks or months and then relapsing ; in a certain number of cases
there are indefinite or atypical symptoms of loose body in the joint ; such as

KNEE-JOINT, DISEASES OF 97

occasional painful locking and inability to extend the limb, especially liable
to occur in walking or in going up a stair ; the locking is usually easily
disengaged and the movements are again quite free. The patient may give
a history of several years of partial and intermittent disability, with lame-
ness and occasional locking, and still he may be able to go about or even
continue his occupation.

On examination of the joint there is usually a moderate degree of
hydrops which subsides under rest ; one is then able to feel ill-defined cords
or tufts or nodular masses, and in the suprapatellar pouch one may be able
to grasp these between the fingers. There is none of the diffuse thickening
of the synovial membrane which is so characteristic of white swelling, there
is little wasting of muscles, and it is quite exceptional to observe any
symptoms of implication of the articular surfaces or the formation of a cold
abscess.

On opening the joint there may escape similar fluid and fibrinous bodies
to those described under hydrops ; with the finger one may feel that the
upper pouch is occupied by fringes, or polypoidal processes, or tumour-like
masses derived from the synovial membrane, they are easily scraped away
with the spoon or finger-nail ; the articular cartilage is usually normal, but
it may be fibrillated as in arthritis deformans.

The diagnosis is to be made from arthritis deformans, and in certain
cases from loose body of other than tuberculous origin ; it is not usually
made with certainty until the joint is opened.

The treatment specially applicable to this type of tuberculous disease
is to perform a partial arthrectomy, and remove the whole of the synovial
membrane which is affected ; in exceptional cases, and especially those in
which there are also foci in the bones, it is better to perform the more
radical operation of excision.

3. Cold abscess or empyema of the knee has been specially observed by
Konig and others, and its outstanding feature is the accumulation of pus
in the joint. It is analogous to the purulent type of peritoneal tuberculosis.
Its clinical features resemble those of tuberculous hydrops so closely that
the differential diagnosis is rarely completed until the fluid, in the joint is
withdrawn by means of a trocar and canula. It is usually the result of a
primary tuberculosis of the synovial membrane. It may be met with in
patients who are up in years as well as in childhood and youth, more often
in those who are much reduced in health, and who are the subjects of tuber-
culous lesions elsewhere. Its development is insidious, often without the
phenomena of inflammation, and its progress is chronic. Like hydrops it
is most often met with in the knee. It is less favourable from the point of
view of prognosis, because the patients affected are usually those of feeble
resisting powers and the subjects of tuberculous disease elsewhere.

Eovsing has described an acute form of tuberculous empyema which
begins suddenly in very young and apparently healthy children, the joint
rapidly swells, becomes sensitive, and the child is feverish. It is liable to
be mistaken for the " acute arthritis " of infants, because evacuation of the
pus by a simple incision usually brings about recovery with complete
restoration of function. The synovial membrane, if examined, shows
miliary tuberculosis.

4. Diffuse Primary Disease of the Synovial Membrane. Synovial Fungus.
White Swelling. — This may follow upon the hydrops and other preceding
types of tuberculous disease of the knee, or it may commence as such.

When the disease is still limited to . the synovial membrane the chief
complaint is of the swelling in the region of the joint. The appearance of
VOL. vi 7

98 KNEE-JOINT, DISEASES OF

the swelling is eminently characteristic ; in contrast to hydrops, in which
it is most marked in the upper pouch, it is here most marked in the vicinity
of the tibio-femoral junction and on either side of the patella ; it gradually
tapers off above and below, so that the swelling is more or less spindle-
shaped or fusiform. As a result of the thickening of the lateral pouch of
the synovial membrane the condyles of the femur may appear to be en-
larged, and on superficial examination one is very apt to think that the
bone is affected. The patient at this stage may limp slightly and keep the
joint a little flexed, and may complain of tiredness and stiffness, especially
at night after exertion. The movements of the joint, although restricted,
are remarkably natural and easy. The wasting of the muscles in front of
the thigh makes the swelling of the joint appear greater than it really is.

When the disease has involved the articular surfaces, and led to partial
destruction or " ulceration " of the cartilages, the disease assumes an aspect
which is much more serious. The previous mobility diminishes and is soon
entirely lost ; this rigidity of the joint is seldom so absolute as that
observed in hip disease ; like it, however, it is chiefly due to the involuntary
contraction of muscles, and it disappears under anaesthesia. There is much
more complaint of pain, which is readily excited by any jar or attempt at
movement, and there are usually " startings " at night. If no treatment is
adopted the knee becomes more flexed, usually to a right angle, the leg and
foot are rotated outwards, and in young patients the tibia is gradually dis-
placed backwards. The wasting of the muscles becomes more pronounced.
The synovial swelling is not only greater in amount, but it often becomes
more boggy in consistence and is hot to the touch. In addition to the
deformity just mentioned there may be a certain amount of genu valgum,
especially if the patient has continued to put the affected limb to the
ground ; under the same conditions the pelvis may be depressed on the
diseased side with apparent lengthening of the limb.

The formation of cold abscess will be referred to later.

5. Primary Tuberculous Disease in the Bones forming the Knee-Joint. — It
is usually impossible to recognise osseous foci in the vicinity of the knee so
long as they are confined to the interior of the bone affected. They remain
latent for long periods, and may even cure without their existence having
been suspected. They may be responsible for certain vague symptoms in
the region of the knee, which are often dismissed as being " rheumatic " or
hysterical; the patient complains of tiredness and aching, aggravated by
exertion, and therefore usually worst at night, and there may be some stiff-
ness of the joint. It is quite exceptional to be able to demonstrate an en-
largement of the bone or tenderness on tapping. Eadiography gives the
most valuable information if the osseous focus be of sufficient size.

If the osseous focus makes its way to the surface outside the limits of the
synovial membrane, the complaint of the patient will be more definite and
localised, there is pain in walking and marked lameness, the bone will be-
come tender on pressure, and a swelling will develop which will gradually
soften into a cold abscess. The joint, although perhaps a little sensitive and
restricted in its movements, and in some cases showing a moderate amount
of effusion or hydrops, may escape infection altogether unless the condition
is neglected or improperly treated. zr^rrt^""

If the osseous focus reaches the surface at the point of reflection of the
synovicd membrane, the membrane becomes thickened, at first in the region
of the osseous focus, the thickening then spreads throughout its whole
extent, and the case then follows the course of ordinary synovial disease,
with the exception that it is usually more stubborn, that it usually goes on

KNEE-JOINT, DISEASES OF 99

more quickly, that there is more pain and rigidity at an early period, and
that abscess is very apt to form soon in the synovial membrane at the point
where the osseous focus has reached the surface. (Watson Cheyne.)

If the osseous focus reaches an articular surface it tends to destroy the
cartilage over it and to infect the joint. The symptoms vary with the
suddenness of the perforation and with the amount of infective material
thrown into the joint. Sometimes the communication between the focus
and the joint cavity is incomplete, and the resulting joint disease evolves
very gradually, and partakes of the character of a dry arthritis with marked
articular symptoms, ■' which is very obstinate, and tends to incomplete
ankylosis, with fixation of the patella and an entire absence of any synovial
fungus. This type is the nearest representative in the knee of what is
called " caries sicca " in the hip or shoulder. Sometimes, on the other hand,
the communication with the osseous focus is shut off by newly-formed
fibrous tissue, and the joint lesion, although similar to the last, is confined to
a limited area such as that of one of the condyles. In exceptional cases a
quantity of tuberculous material may be discharged suddenly into the joint,
and we may have the following clinical features as described by Watson
Cheyne : — " The patient experiences sudden severe pain, probably at the
time of perforation, followed by swelling of the joint and in some cases by
fever, the whole joint becomes rapidly infected, the surface of the synovial
membrane undergoes caseation, and the cartilages are quickly destroyed.
In this condition some cheesy pus is generally formed at an early period, in
the joint, the patient suffers much pain, especially on the slightest move-
ment, there is starting pain at night, the knee is flexed and rigid. When
abscesses form and are opened they are found to communicate with the
joint, the bones are carious, and if recovery takes place there is bony
ankylosis."

The Formation of Abscess in Tuberculous Disease of the Knee. — Statistics
show that suppuration and sinuses are met with in rather more than 50
per cent of cases, and that the influence of these on the prognosis is decidedly
unfavourable. Although abscess formation may take place at any stage in
the progress of the disease, it occurs more frequently after symptoms of
involvement of the articular cartilages have manifested themselves.
Abscesses may originate in the substance of the synovial membrane, and
spread externally to the periarticular soft parts, or they may originate in
the joint itself ; within the joint the suppuration is often confined to one
or more areas which have been shut off from the general cavity, e.g. in the
suprapatellar pouch, or in the area of one or of both femoral condyles. A
cold abscess may also form in relation to one of the bursas in the popliteal
space. If untreated the abscess tends to spread into the periarticular
tissues, into the popliteal space, and down the back of the leg, or upwards
into the thigh between the vastus internus and adductors on the inner
side, and along the edge of the vastus externus on the outer side ; such
abscesses may extend for a considerable distance, and by infecting extensive
tracts of tissue, increase the risk of general tuberculous infection. Abscesses
on the anterior aspect of the upper part of the leg are less common, and
result chiefly from foci in the patella or in the head of the tibia.

The sinuses which result from the external rupture of abscesses are
often multiple and extensive, and by allowing of the entrance of septic
infection, and by militating against the primary healing of operation wounds,
are always to be regarded as a serious aggravation of the disease and an
additional risk to the life of the patient.

Diagnosis of Tuberculous Disease of the Knee. — The diagnosis of tuber-

100 KNEE-JOINT, DISEASES OF

culous hydrops has been referred to under this head. There is usually no
difficulty in recognising typical cases of white swelling. In some cases the
thickening of the synovial membrane may resemble in certain respects the
much rarer condition of perisynovial gummata ; the latter are chiefly met
with in women ; the gummatous swelling is more nodular, uneven, and less
uniform than the tuberculous; there are frequently tertiary ulcers or
depressed scars in the neighbourhood of the patella, and the joint symptoms
are less prominent. When there is in addition gummatous disease of the
tibia or femur, with sinuses leading down to carious bone, the diagnosis may
be extremely difficult, especially as the overwhelming frequency of tuber-
culous disease predisposes one to assume that the disease is of this nature,
and the syphilitic origin is apt to be missed because it is not suspected.

The very early stages of tuberculosis and of arthritis deformans of the
knee may resemble each other very closely, because the respective clinical
peculiarities have not had time to develop. Difficulty is met with,
especially in adults, who complain of pain, stiffness, and lameness, and who
present a moderate amount of swelling of the joint with or without
effusion. In arthritis deformans the progress is more intermittent and
erratic, the symptoms are rather aggravated than improved by rest, and
they are influenced by changes in the weather. The presence of crackings
or of creaking on movement, the sensation of roughness or crepitation on
grasping the joint while it is rapidly flexed and extended, and, finally, the
presence of crackings and irregular pains in other joints, may be of help in
recognising arthritis deformans.

A resemblance between tuberculous and pyogenic affections of the -knee
may arise when there is a partial infection of the joint, resulting from a
focus in one of the neighbouring bones. There is less likelihood of mistake
when the tuberculous lesion assumes, as it does occasionally, an acute
character, because the general feature and the progress of the disease clear
up the difficulty before much time has been lost. Staphylococcus lesions, on
the other hand, e.g. Brodie's abscess, whether in the upper end of the tibia
or lower end of the femur, may run a chronic course, and may be associated
with changes in the knee-joint (swelling, effusion, adhesions) which are very
similar to those resulting from tuberculosis. The history of the case and
the local features must be gone into very carefully, and the bones should be
examined by radioscopy.

Cases of tuberculous disease of the knee may occasionally present
themselves with the , symptoms of loose body in the joint ; the recognition,
however, of the other evidences of joint disease is usually sufficient to
differentiate them from the more numerous group of cases in which the
loose body (or bodies) is the only discoverable lesion in the joint.

Cases are on record in which treatment has been carried out for tuber-
culous disease of the knee, and in which the after progress has shown
the patient to be suffering from sarcoma of the lower end of the femur, or of
the synovial membrane of the knee.

It may be instructive to refer to the points in which disease of the knee-
joint, and sarcoma, especially of the lower end of the femur, resemble one
another : the initial symptoms are often those of vague pains and of a limp,
which may be relieved for a time by rest or by the application of a blister ; at
a later stage the characters of the swelling may be deceptive, as the tumour
tissue may project from the bone into the upper recess of the joint ; the
swelling may be hot and tender, the muscles may be wasted, and the joint
may be flexed and stiff; there may be considerable evening pyrexia greater
than that observed in tuberculous disease of the knee ; in the latter affection

KNEE-JOINT, DISEASES OF 101

the temperature is usually quite normal so long as the patient is confined
to bed. The following are the chief points favouring the diagnosis of
sarcoma : — There is often a history that the swelling was first noticed on one
side of the joint ; the swelling is more often uneven or nodular ; it does not
accurately correspond to the shape of the synovial membrane, but extends
beyond the limits of the joint, and involves the bone to a greater extent
than is usual in cases of joint disease. The swelling is also more unequal in
consistence, being harder than the synovial fungus in some parts, and softer
or fluctuating in others. If a trocar and canula is pushed into the swelling
it may be felt -to grate on roughened bone, or may even perforate the thin
shell of the tumour, and it only abstracts blood. It is useful in difficult
cases to confine the patient to bed, and fix the limb in a splint for a week
until the oedema of the soft parts and any fluid in the joint have been
absorbed ; the nature of the swelling, and the presence or absence of joint
symptoms, can then be determined with greater accuracy. Eadiography is
most useful in cases where the bone is expanded by the tumour, or where
much new bone is formed as in the ossifying sarcoma. Finally, recourse
should be had, without too long delay, to exploratory incision and immediate
microscopic examination of the suspected tissue elements. The diagnosis of
hysterical affections of the knee is the same as in other joints. The " bleeder's
knee " met with in the subjects of hsemophylia may resemble tuberculous
disease very closely indeed, especially when repeated hemorrhages have taken
place into the joint, and the latter has become swollen, stiff, and flexed.
The differential diagnosis is considered in paragraph 6, p. 110.

The prognosis in tuberculous disease of the knee is chiefly concerned with the
possible retention or loss of the functions of the joint, and in the case of chil-
dren with the future growth of the limb. In hydrops and in mild forms of
primary synovial disease recovery with a movable joint may be confidently
anticipated. "When the articular surfaces are seriously implicated, recovery
with mobility is most unlikely ; on the other hand, the occurrence of rigid
and preferably osseous ankylosis affords the best prospect of permanent
cure. Inasmuch, however, as this result can only be attained under expectant
conditions, with considerable loss of time, there is great inducement to
securing this result more rapidly and with greater certainty by means of an
operation which will at the same time remove the disease. Most of the
deformed and shortened limbs from knee-joint disease to be seen on our
streets are capable of prevention.

As regards the prognosis to life we may cite the statistics of Konig. Out
of 615 cases observed at the Gottingen clinique over a period of eighteen
years no less than 205 succumbed (33| per cent) chiefly from tuberculosis
of the lungs and other internal organs.

Treatment of Tuberculous Disease of the Knee. — As in other joints, this
may be discussed under the headings of conservative and operative.
Conservative measures are specially applicable in children, and that for
several reasons : in them spontaneous recovery is much more likely to take
place than in adults ; time is of secondary importance, because there is no
question of their having to earn a living ; excision, which in the case of the
adult restores a usable limb with great certainty, is to be avoided in children,
because it may lead to interference with growth ; and, finally, the alter-
native operation, arthrectomy, is unreliable as to the functional results
obtained. On the other hand, adults, and especially breadwinners, cannot
be expected to wait two or three years for a problematical spontaneous
recovery when one can promise an almost certain cure within a definite
time by means of excision. It cannot be too strongly insisted upon that it is

102 KNEE-JOINT, DISEASES OF

not only waste of time but a source of danger to the patient to persist with
conservative measures in cases in which spontaneous recovery is impossible
or unlikely. Konig's statistics, which cover a period of eighteen years,
bring out the remarkable fact that a larger proportion of patients finally
succumbed among those submitted throughout to expectant treatment, than
among those in which the disease was removed by operation.

Conservative Measures. — These are to be employed in the first instance,
unless, as already stated, the condition of the patient or of his joint is such
as renders the prospect of spontaneous recovery with a useful limb unlikely
or impossible, and with this reserve, that if the disease does not yield, we
must not hesitate to have recourse to operation.

(a) The Joint must be 'put at Best in the Extended Position. — The patient
should be confined to bed during the initial period of treatment. If the
joint is flexed and sensitive it should be supported on a pillow, and exten-
sion by the weight and pulley is applied to the leg until the limb is straight.
Genu valgum deformity is more difficult to get rid of than flexion ; if it
does not yield to extension, the bones should be forcibly brought into line
with one another under an anaesthetic. Once the limb is straight, it must be
kept so by suitable apparatus, e.g. a trough of Gooch, known as Watson's
splint, a gutter of wire or basket work with a foot-piece, lateral poroplastic
splints secured with an elastic webbing bandage, or plaster of Paris. The
external application of iodine, mercurial ointment, or of fly blisters does not
appear to have any curative influence. If the disease readily yields to
treatment by rest alone the patient may be allowed to leave his bed, but
the fixation of the joint and the extended position of the limb must be
maintained by a Thomas or other suitable splint for a period of at least
twelve, months. The splint is removed at intervals for hydrotherapy,
massage, and electricity of the atrophied muscles and passive move-
ments of the ankle. Before the splint is discarded altogether, it may
be left off during the night; it is ultimately replaced by an elastic
bandage.

(b) Venous Congestion by Bier's Method. — This method of treatment is
variously appreciated by different observers, and is still sub judice. Some
cases appear to improve under it more rapidly than with rest alone ; it may
therefore be combined with the latter, i.e. either while in bed or going
about with a Thomas splint ; if there is no decided improvement in a
fortnight it should be abandoned.

(c) Injection of Iodoform Glycerine. — The details of this method have been
described in the general article on Joints. So far as the knee is concerned
it is most easily introduced and most efficient in cases of hydrops. In the
more common synovial fungus or white swelling the injection is more
difficult, more painful, and requires to be repeated more frequently and at
shorter intervals (10 days to 3 weeks). The value of iodoform injection, as
of venous congestion, is variously estimated by different observers. By some
it is accepted as a method of treatment which has very largely done away
with the necessity for operation, by others it is regarded as capable of
bringing about an improvement which is only temporary. Our own ex-
perience is decidedly encouraging.

(d) The treatment of abscess is conveniently included with the conserva-
tive methods. One of the objects of keeping a patient with tuberculous
joint disease under observation is that of recognising an abscess at the
earliest possible moment. When discovered it should be treated by the
iodoform glycerine method, as already described in the article on Joints, q.v.
If the abscess does not yield to the iodoform treatment it should be cleared

KNEE-JOINT, DISEASES OF 103

out by operation ; in doing so, if an osseous focus is discovered it should be
cleared out at the same time.

(e) Treatment of Extra-articular Tuberculous Foci in the Bones. — Inter-
mediate between the conservative and operative treatment, the question may
arise of clearing out osseous foci in the neighbourhood of the knee, either to
prevent infection of the joint, or, where this has already taken place, to increase
the chances of cure by conservative measures. The great difficulty is to
diagnose the foci in question apart from abscess formation, for the symptoms
are not at all definite. Local pain, tenderness, thickening, or enlargement
of the bone may indicate a focus, especially in the head of the tibia or in
the patella. The proper treatment is to cut down on the bone, remove any
infected soft parts en masse, clear out the focus in the bone with the spoon,
gouge, or chisel, and stuff the cavity with iodoform gauze. If the joint is
opened into in this procedure, the technique will depend on the state of the
synovial membrane ; if healthy, the opening into the joint may be closed
with sutures ; if there is circumscribed disease of the synovial membrane it
may be clipped away ; if the thickening of the membrane is more exten-
sive, the joint may be filled with iodoform glycerine and closed ; if the
joint as a whole is diseased, then the case is one for arthrectomy in children
or excision in adults.

The above described partial operations are especially successful in
children ; in the adult they are less certain to cure and more dangerous to
life than the more radical operation, viz. excision.

Operative Treatment of Tuberculous Disease of the Knee. — The operations
concerned are arthrectomy (erasion), excision, and amputation. When the
disease has implicated all the structures of the joint, and spontaneous
recovery is unlikely, and is in any case likely to be attended with a stiff
joint, it is waste of time to persist with conservative measures when the
same result may be obtained with rapidity and certainty by means of an
operation which will also at the same time get rid of the disease. Among
the indications for operative treatment in disease of the knee in contrast to
other joints, we should therefore place in the front rank the hopelessness of
obtaining a movable joint, as inferred from symptoms of destruction of the
articular cartilages, rigidity, pain on the slightest attempt at movement,
startings at night, and fixation of the patella. In the second rank may be
included cases which are unsuited for conservative treatment, e.g. where
there is deformity incapable of being rectified otherwise, or when the general
health requires that the disease should be removed by the most rapid
method. In the third group we should include cases in which the disease
progresses in spite of a fair trial of conservative measures, in which the
synovial thickening is increasing or is showing signs of softening, or where,
from the mere persistence of the disease, there is reason to suspect the
existence of serious disease in the bones, or finally, where the disease has
relapsed after apparent care under expectant treatment. Other things being
equal, the fact of the patient being an adult would determine the balance
in favour of operation.

Having decided on the necessity of operation, the next and almost
equally difficult question to decide is as to its nature. There is consider-
able difference of opinion regarding the wisdom of aiming at a movable
joint, and of recommending arthrectomy with this object in view. Increas-
ing experience of the results of this operation shows most conclusively that
a movable joint, which will at the same time be useful, is exceedingly rare, —
so rare, in fact, that the question of mobility should scarcely be entertained.
As has aptly been pointed out by Konig, it is hardly reasonable to expect

104 KNEE-JOINT, DISEASES OF

mobility after removing the entire capsule and synovial membrane, upon
which the mobility of the joint depends. There is another side to the
question, viz. that the slight extent of mobility secured by an arthrectomy
may not always be an advantage to the patient, inasmuch as it may permit
of gradually increasing flexion and disabling deformity of the limb. It is
also maintained that the disease is more liable to relapse after arthrectomy
than after excision, both because the disease is less radically removed, and
because the remanent mobility exposes the limb to strain far more than if
there were a rigid ankylosis.

The real advantage claimed for arthrectomy is that it not only avoids
any immediate shortening of the limb, but also that it does not interfere
with its future growth. On these grounds alone it is to be preferred to
excision, in patients under fifteen or sixteen years of age. In performing it,
however, one must not be hampered with the obligation of aiming at a mov-
able joint ; if the articular surfaces are affected they must be pared with a
strong knife. After the wound has healed, means must be employed to prevent
flexion for a period of two years. If at the end of this period the joint is
found to have retained a certain degree of mobility, well and good, but one
must not sacrifice the greater certainty of curing the disease and of obtain-
ing a useful limb, for the doubtful advantages of mobility. In adults the
operation of excision is preferred because there is no question of interfering
with growth.- The ends of the bones are removed by means of a saw, the
sections being made in such a way as will secure the most accurate and most
rigid adaptation to one another, and the certainty of bony ankylosis. Am-
putation is indicated, whether in children or in adults, in cases where
arthrectomy or excision is incapable of removing all the disease. It should
not be reserved for hopeless cases.

Arthrectomy of the Knee. — Evasion. — Flexion of the joint should, if possible, be
corrected before operation by means of extension with the weight and pulley, in
order to stretch the structures in the ham. There are several methods of perform-
ing the operation : those in which a transpatellar or H -incision or an anterior
U-shaped flap is made, have this in common, that the patella or its ligament is
divided transversely. Other methods are to be preferred which maintain the
integrity of the extensor apparatus, viz. that by two vertical incisions, one on
either side of the patella, or the single large external J-shaped incision of Kocher.
We shall describe the last-mentioned operation. The limb should be rendered
bloodless in the usual way. The incision is made upon the outer aspect of the
joint. It begins a hand's-breadth above the upper margin of the patella, and at
first descends vertically at a distance of two fingers'-breadths from the outer border
of that bone. It then inclines gently inwards, and terminates on the inner aspect
of the tibia, a little below the tubercle. The fat and fascia lata are divided in
the line of the incision, and at the upper part the fibres of the vastus externus.
The capsule is then divided over the outer condyle of the femur and along the
outer edge of the ligamentum patellae. By means of the chisel the tubercle of the
tibia, along with the ligamentum and periosteum, are displaced inwards. One then
proceeds to remove the synovial membrane and semilunar cartilages, and in doing
so excellent access is obtained by dislocating the patella inwards, while at the
same time the joint is more and more flexed. If it is desired to clear out the
posterior pouch of the joint, the femoral attachments of the lateral and crucial
ligaments may be separated, along with the periosteum and bone, by means of the
chisel. The articular surfaces are carefully inspected, and any suspicious areas
are scooped out with the spoon. If there is genu valgum it may be corrected
by paring the articular surfaces of the inner condyle and internal tuberosity to
the extent required. Iodoform powder is rubbed into the surface and recesses of
the wound. The divided capsule and other ligamentous attachments are sutured
so as to re-establish the stability of the joint. Drainage may be provided for by
means of a rubber tube or a strand of iodoform gauze or worsted. If there is any
doubt as to the likelihood of primary healing the cavity of the wound should be
packed with iodoform gauze or worsted. The entire limb from the tuber ischii to

KNEE-JOINT, DISEASES OF 105

the malleoli is then enveloped in plaster of Paris, or enclosed in a long splint.
When the wound is soundly healed the patient is provided with a Thomas splint,
which must be worn for a period of not less than two years in order to prevent
flexion of the joint. During the whole of this time the patient should be kept
under observation.

Flexion after Arthrectomy. — If the patient has been allowed to put the
limb to the ground, or has been otherwise neglected, the knee is very apt to
become flexed, and this deformity once started is almost certain to increase
by the mere weight of the body in walking. In a small number of cases,
and especially in rickety children, the flexion may be partly due to a
forward curve of the lower part of the shaft of the femur. The deformity
may be corrected by linear osteotomy (using a broad chisel) either across
the knee-joint from the front, or in addition where the femur is curved, by
a second osteotomy in the lower third of the shaft.

Relapse of the disease after arthrectomy is to be treated by excision or
amputation.

Excision of the Knee. — Inasmuch as the double object of this operation is
to remove every particle of disease, and to secure rigid bony ankylosis, there
is no longer any question, as in arthrectomy, of preserving ligamentous con-
nections between the bones, or of preserving the extensor apparatus. The
subcapsulo-periosteal method of Oilier, which presents such advantages in
other joints, is quite out of place in the knee. The surgeon should aim at
removing the antero-lateral portions of the capsule and synovial membrane,
along with the patella and its ligament, in one piece, as if he were engaged
in the removal of a malignant tumour (A. G-. Miller, Kocher). At the end
of the operation, the sawn ends of the femur and tibia should be covered by
nothing but skin and fascia.

The incision employed should be one giving free access to the whole area of the
joint. Kocher's external incision, already described in the operation of arthrec-
tomy, or a large anterior U-shaped flap may be employed. In view of the supei1-
fluity of skin in cases where the knee is flexed, or where there is considerable
swelling, an elliptical portion comprising that over the patella may be removed.
This, which is a matter of choice in most cases, becomes compulsory when this area
of skin is the seat of a sinus. By whatever incision the anterior aspect of the
joint has been exposed, the next step should be to divide the connections of the
vasti and rectus femoris with the upper part of the capsule, so as to allow of
exposing the upper limit of the suprapatellar pouch. The more common procedure
of sawing across the patella, or of dividing the ligamentum patellar, and immedi-
ately opening the cavity of the joint, is to be deprecated, both because it makes it
more difficult to define the upper pouch, and because it exposes the wound from
the outset to tuberculous infection. The suprapatellar pouch is then dissected off
the femur, in front and on both lateral aspects, until its reflection on to the cartil-
aginous surface of the femur is approached. The ligamentum patellar is divided,
and the lower limbs of the capsule and synovial membrane are similarly dissected
off the tibia from below upwards until the articular surface is reached. Having
divided the lateral ligaments and flexed the joint, the capsule, synovial membrane,
patella, ligamentum patellse, infrapatellar pad of fat, and the semilunar cartilages,
are removed in one tumour-like mass. The posterior recess of the joint is then
displayed by detaching the crucial ligaments, and by flexing the joint until the
femur and tibia are nearly parallel with one another. Not only must the posterior
part of the capsule and synovial membrane be removed, but also any disease in the
popliteal bursa. The sharp spoon is not so reliable as the scissors or knife. The
risk of wounding the popliteal artery during this step of the operations is probably
exaggerated. Iodoform powder is rubbed into the raw surfaces and recesses of
the wound. Having cleared the ends of the bones the articular surfaces are
removed by means of the saw. Skill is required in order to do this, so as to insure
that the sawn surfaces will be capable of being accurately applied to each other
in the extended position of the limb. The usual procedure is to saw the bones at
right angles to the long axis of the limb, i.e. parallel to their articular surfaces,
and to employ for this purpose an ordinary amputation saw. If the sawn surfaces

106 KNEE-JOINT, DISEASES OF

fit accurately they are merely placed in contact, otherwise they may be retained
in apposition by means of two long steel pins introduced through the skin beyond
the excision wound. The pins should not be driven home until the limb is placed
in the splint in the extended position. Kocher makes with a narrow butcher's
saw a convex section of the femur and a concave section of the tibia. This method
of sawing the femur in the case of growing limbs has the advantage of being least
likely to damage the epiphysial cartilage, but it is a little more difficult to carry
out successfully. Whatever method is employed for sawing the bones, if tuber-
culous foci are discovered on the sawn sections, they should be cleared out with
the gouge in preference to taking away another slice of the bone. The tourniquet
is removed and the blood-vessels are ligatured. The wound is closed, and drainage
is provided for by a rubber tube brought through an opening in the skin at the
outer side. The limb is maintained in a box or simple posterior (Watson) splint
until the wound is soundly healed. Plaster of Paris is then applied, and the
patient allowed to go about on crutches. Three months after the operation the
plaster case may be exchanged for a Thomas splint, which should be worn for six
months or a year.

Mortality of Excision. — Apart from the risks attending any major
operation, the chief causes of death following excision of the knee are
phthisis pulmonalis and general tuberculosis.

Results of Excision. — In the majority of cases the disease is permanently
cured, and there is rigid ankylosis at the tibio-femoral junction. The more
rigid the ankylosis the more useful is the limb. Very slight flexion,
amounting to 5° or 10°, is the best attitude for walking. The shortening
directly due to the operation varies with the amount of bone removed ; it
varies from ^ to 2 inches, and it is easily compensated for by depressing the
pelvis on the same side, or by thickening the sole of the boot. If shortening
already existed before the operation, the combined shortening may necessitate
the use of a high boot. When excision has been performed in a limb which
is still growing, and the epiphysial cartilages are removed, the shortening
may amount to as much as 6 inches. A very obstinate form of flexion is
sometimes observed in young subjects as a result of removing the posterior
two-thirds of the epiphysial cartilage of the femur. The anterior portion
which is left continues to develop bone, and the original plane of section no
longer remains at a right angle to the axis of the limb. In order to correct
it a wedge-shaped portion of bone must be removed.

In fibrous ankylosis, unless it is very close and strong, a Thomas splint
or other form of apparatus must be worn until the desired stability is
acquired. The relapse of tuberculous disease in the shape of abscesses and
sinuses is to be treated on the usual lines.

Amputation is reserved for severe and usually neglected cases ; where the
disease extensively involves the bones, and is rapidly advancing with
evidences of suppuration, where there are septic sinuses, especially after
the failure of excision to secure a useful limb, and where the lungs and
other internal organs are seriously implicated. It is often remarkable how
much the lung disease may improve after the removal of suppurating
tuberculous disease of the knee.

The amputation should be performed well above the limits of the
infected tissues, whether synovial membrane or cellular tissue.

In view of the unfavourable nature of the cases submitted to amputation
it is not surprising that the mortality is a high one, especially if we include
those cases which die some time after the operation from phthisis or general
tuberculosis.

Treatment of Deformities resulting from Antecedent Disease of the Knee. —
We are here concerned with cases in which the disease has been recovered
from, but the joint has been allowed to assume the flexed position, with or
without backward displacement of the tibia.

KNEE-JOINT, DISEASES OF

107

When the deformity is of the nature of a contracture, in which the
articular surfaces are fairly preserved, and the flexion is due to the con-
traction of the posterior part of the capsule and the soft structures in the
ham, extension may be given a trial, but if it fail, all the shortened struc-
tures should be divided by the open method, by means of an oblique incision
made from above downwards across the popliteal space. Forcible correction
of the deformity is to be avoided unless it be done in stages ; with each step
towards the extended position the limb is to be encased in plaster of Paris.

When there is fibrous or osseous ankylosis in the flexed position the
procedure varies in different cases. In patients who are still growing, one
may succeed with a modified arthrectomy and the removal of a thin slice of
bone. In adults the usual procedure is to remove a wedge of bone. In the
bony ankylosis of growing patients, we may either divide the femur above
the level of the joint, or wait until the patient is nearly fully grown, and
remove a wedge of bone as in the adult. When the flexion is extreme
there is a risk of overstretching the popliteal vessels, and of interfering
with the circulation in the foot ; in these cases it is safer to remove another
shoe of bone.

When there is a genu valgum deformity, one may practise an osteotomy
of the femur as in rickety knock-knee.

3. Pyogenic Diseases

Acute and chronic serous synovitis.
Purulent synovitis.
Acute arthritis of infants.
Joint suppurations in pyemia.
Severer forms of septic arthritis.
Infections from penetrating wounds
Gonorrhoeal affections of knee.

Acute osteomyelitis of lower end of

femur.
Acute osteomyelitis of upper end of

tibia.
Chronic osteomyelitis — Brodie's

abscess.

These include a number of diseased conditions resulting from infection
through the blood-stream of the joint, or of the structures in its neighbour-
hood, with the common pyogenic organisms, or with special bacteria such as
the gonococcus or typhoid bacillus. The direct infections resulting from a
penetrating wound of the joint may also be conveniently described under
this head.

The clinical features vary with the gravity of the infection, and are very
similar to those met with in other joints. They may assume the form of an
acute serous synovitis, which may recover spontaneously, or may subside into
a chronic synovitis or hydrops. Exudation into the joint is always a promi-
nent feature. A characteristic persistent and relapsing form of hydrops is
met with in the knee, in association with latent forms of staphylococcus
osteomyelitis, e.g. Brodie's abscess, in the lower end of the femur or upper
end of the tibia.

The purulent forms of synovitis in the knee present wide variations
with regard to their severity and progress. There are certain mild forms,
called " catarrhal " by Yolkmann, in which the joint fills with pus without
any periarticular phlegmon, and without any destructive changes in the
joint, and in which, if the pus is evacuated, recovery usually takes place
with complete restoration of function. This type is most often observed in
the " acute arthritis of infants," related to staphylococcus osteomyelitis of
the tibial or femoral epiphysis, or one of the adjacent ossifying junctions.
The joint suppurations in pycemia, which especially affect the knee, are
usually remarkably latent. There is, however, no hard and fast line between

108 KNEE-JOINT, DISEASES OF

the milder forms and those which are serious and progressive ; in addition
to the presence of fluid (sero-pus or pus) in the joint, there is a pronounced
periarticular phlegmon, oedema of the surrounding skin, and it may be of
the leg and foot, destructive changes in the articular surfaces in the direc-
tion of caries, attended with severe pain, rigidity of the joint, and startings
at night; the pus within the joint perforates the capsule and spreads
upwards into the thigh beneath the quadriceps, backwards into the
popliteal space infecting the bursae, and downwards into the calf. The
septic fever accompanying the severer forms of septic arthritis may readily
merge into pyaemia, and cause the death of the patient. The author has
observed one case of destructive purulent arthritis in the knee of an adult,
which had become stiff from disease in childhood ; the relapse in adult life
appeared to have originated from a recent pyelitis ; both the bones and the
soft parts in the region of the knee were riddled with suppuration, and in
spite of amputation through the thigh the patient died of septicaemia.

The septic synovitis and arthritis following upon penetrating wounds of
the knee are usually of a severe and progressive character ; they are met with
more commonly from accidental wounds with a chisel, or awl, or penknife,
or the spike of a railing, from gunshot wounds, or compound fractures
involving the knee, but they may follow upon such operations as wiring a
fractured patella, removing a loose body or semilunar cartilage.

Practically all the severe forms of pyogenic arthritis result in ankylosis,
which is more often osseous than fibrous ; in treating them, it is therefore of
great importance to keep the bones in a straight line by means of splints
and weight extension.

The treatment in pyogenic diseases of the knee must be directed to meet
the features of each individual case. The general indications are to elevate
and immobilise the limb in the extended position on a posterior splint,
preferably a gutter of Gooch's splinting reaching from the fold of the
buttock to beyond the foot, and to apply an antiseptic fomentation over
the entire area of the joint. If there is exudation into the joint with much
tension, the fluid should be withdrawn by means of a trocar and canula
inserted obliquely into the suprapatellar pouch. If the fluid is purulent
a free incision should be made into the joint above and to the outer side of
the patella, and a drainage-tube is introduced. If this does not arrest the
local progress of the disease or the general toxaemia, the patient should be
anaesthetised, incisions should be made on either side of the patella, freely
opening the capsule and suprapatellar pouch, and drawing through tubes
from one side to the other. The drainage may be further improved by
pushing a dressing forceps between the bones into the popliteal space, and
making an opening there, through which a large rubber tube may be drawn
backwards into the joint. Periarticular suppurations must be searched
for, and. if found, should be opened and drained. The more complete the
apparatus for drainage the more thorough is the subsequent irrigation.
Saline solution may be employed to wash away pus, blood, and fibrinous
material; peroxide of hydrogen and sulphurous acid are the most useful
chemical agents for irrigation purposes. Cases are met with, especially
those from direct infection through a wound, in which, in spite of all one's
efforts in draining and irrigating, the temperature continues to rise, the
patient loses ground, and anxiety for the joint yields to anxiety for the life
of the patient. The choice of procedure will consist in laying the joint
freely open from side to side, dividing the ligamentum patellae and capsule,
and packing the cavity between the bones with gauze, or excising the joint
or amputating through the thigh.

KNEE-JOINT, DISEASES OF 109

The gonorrheal affections of the knee have been sufficiently considered
in the general article on joints ; one may refer, however, to the predomi-
nance of hydrops, which may prove very obstinate, and in which one may
find it necessary to evacuate the fluid through a canula, and to irrigate
the joint with protargol.

Acute Osteomyelitis of the Lower End of the Femur. — The lower femoral
epiphysis and the adjacent ossifying junctions are very common seats of
this disease ; at its onset it is frequently mistaken for an affection of the
knee-joint, and regarded as rheumatic in nature. The lower end of the
bone should be carefully palpated and compared with that of the sound
limb, and considerable reliance in diagnosis may be placed on the recogni-
tion of the point or points of maximum tenderness. In the operative
treatment of femoral osteomyelitis the incision should be made on the
outer aspect of the limb in the line of the intermuscular septum ; having
divided the fascia lata, a grooved director may be pushed inwards to
discover the presence of pus beneath the periosteum ; the opening thus
made may be enlarged with dressing forceps so as to admit the finger, and
permit of investigating the locality and extent of the disease ; the trigone
of the femur is often found to be denuded of periosteum, and is especially
liable, in neglected cases, to become the seat of necrosis.

In acute osteomyelitis of the upper end of the tibia the superficial
situation of the bone is of great assistance in diagnosis and in operative
treatment.

Chronic forms of osteomyelitis, e.g. Brodie's abscess, attain their maximum
frequency in the lower end of the femur and upper end of the tibia ; some-
times a sinus may extend from the abscess into the knee-joint, but even
then the communication is valvular, so that it is exceptional to have a
generalised pyogenic arthritis ; more commonly the joint suffers from the
formation of adhesions, and the conversion of the articular and inter-
articular cartilages into fibrous tissue, or it may fill with fluid, constituting
one of the forms of relapsing or intermittent hydrops.

5. Arthritis Deformans. Osteo- Arthritis. — This may affect the knee only,
or may be polyarticular. It may follow upon injury of the joint or of the
bones in its vicinity. The changes related to the synovial membrane attain
their maximum in the knee, and may assume the form of hydrops with or
without fibrinous bodies, or of overgrowth of the synovial fringes, and the
formation of pedunculated loose bodies. The changes in the articular
surfaces and margins are more easily recognised in the knee than in other
joints ; fibrillation of the cartilage imparts a feeling of roughness or friction
when the joint is firmly grasped during flexion and extension, while lipping
of the margins of the trochlear surface of the femur is readily estimated
after comparison with the healthy joint. When a portion of the " lipping "
is broken off it may give rise to the symptoms of loose body. In advanced
cases of hydrops the ligaments become stretched, and there may be lateral
movement with grating of the articular surfaces.

Among therapeutic measures applicable to arthritis deformans of the
knee, we have observed considerable improvement following tapping of the
joint, in cases of hydrops, and injection of iodoform glycerine ; there is a
sharp reaction and increase of the pain and the swelling for a day or two.
"Where the patient's sufferings are chiefly due to the presence of hyper-
trophied fringes, pedunculated loose bodies, or a detached portion of the
lipped articular margins, great relief may follow on opening the joint and
removal of the offending fringes or bodies. When the disease is of a very
aggravated type, is mono-articular, and is the cause of serious crippling in a

110 KNEE-JOINT, DISEASES OF

patient who is otherwise in good health, the question of excising the joint
should be considered.

6. Hcemophylia — "Bleeder's Knee." — This is a rare but very characteristic
affection, chiefly met with in boys and young adult males. The first
haemorrhage into the joint originates suddenly after some trivial injury,
and may attract so little attention that it is not thought necessary to seek
advice ; the appearances are very similar to those of hydrops, and there is
little or no pain ; the patient is usually anaemic, but is otherwise healthy ;
the temperature is often elevated (101°-102°), especially if at the same time
there are haemorrhages into the cellular tissue of other parts of the limb or
elsewhere in the body. After repeated haemorrhages the joint becomes
uniformly swollen from the deposit of fibrin on the synovial membrane and
its subsequent organisation. As the swelling is often associated with flexion
and stiffness the resemblance to white swelling is very close indeed, — so
much so, indeed, that a wrong diagnosis has been made, and the joint sub-
jected to operation with disastrous results. The treatment of bleeder's knee
has been described in the article on joints.

7. Neuro- Arthropathies. — Charcot's disease more often affects the knee
than any other joint ; it is chiefly met with in adult males suffering from
lightning pains and loss of the knee-jerks. In the knee it often presents
the features of an immense hydrops with oedema of the leg and foot, but
whatever the external appearances, the presence of abnormal movements,
lateral or rotatory, with cross grating and the utter absence of sensitive-
ness, are very characteristic ; in many cases it is possible to partially or
completely dislocate the tibia from the femur.

8. Hysterical knee may be regarded as the type of hysterical joints, being
the one most commonly affected. It has been described as such in the
general article on joints (see also "Hysteria, Surgical aspects of,"
vol. v.).

9. Loose Bodies. — The origin, structure, and clinical features of loose
bodies have been discussed in the general article on joints (p. 1); we may here
refer to the operation for their removal. The incision is made directly over
the body whenever it can be located to a particular area of the joint. If on the
other hand the body is free and has to be searched for, the joint must be
freely opened, preferably by a vertical incision along the outer border of the
patella, so as to admit the finger. The limb must be carefully manipulated
during the exploration, or the finger may be severely nipped between the
patella and the femur. If the body lies in the posterior recess of the
joint one may fail to find it through an incision made on the anterior
aspect of the joint; under these circumstances the whole joint must be
opened up, and this is best carried out by detaching the tubercle of the
tibia, and dislocating the patella inwards, as has been already described in
the operation of arthrectomy by Kocher's method. One should always
remember that there may be more than one loose body in the knee-joint.

10. Pathological Dislocation. — Apart from the backward displacement of
the tibia observed in tuberculosis, pathological dislocation is almost confined
to cases of Charcot's disease.

11. Congenital Dislocation of the Knee. — The tibia is nearly always dis-
located forwards, and the patella is frequently absent. When the dislocation
is bilateral it is often accompanied with other errors of development. In
congenital dislocation of the tibia forwards, the joint is in a state of hyper-
extension which may be increased or diminished by manipulation. The treat-
ment consists in flexing the knee, under an anaesthetic, as nearly to a right
angle as possible, and fixing it in this position with plaster of Paris or other

KNEE-JOINT, DISEASES OF 111

apparatus. Where the patella is absent it is usually necessary to produce
an artificial ankylosis between the femur and tibia.

Spontaneous dislocation of one or loth knees may be observed in infants ;
in older children the patient may be able to dislocate the joint voluntarily.
J. W. Ballantyne records ^the case of an infant of eleven months old, in
which the right knee was frequently dislocated outwards during attempts
at walking ; on examining the limb it was found that when the leg was
grasped in the position of nearly complete extension, and the upper end of
the tibia was pressed outwards, that a partial dislocation of the tibia took
place with a slight creaking noise ; the dislocated tibia was easily reduced,
and the whole procedure did not appear to cause the infant any pain.

In this and similar cases the joint should be fixed on some retentive
apparatus until the joint acquires the desired stability.

12. Congenital Dislocation of the Patella. — There are several varieties of
this lesion. The complete persistent form, in which the knee-cap rests on
the outer surface of the external condyle in all positions of the joint, is
extremely rare, and is usually combined with congenital knock-knee, or
with marked external rotation of the leg. Both deformities may be cor-
rected by manipulative treatment if this is begun in early infancy.
The spontaneous or intermittent form, in which the knee-cap is only displaced
outwards when the knee is flexed, is chiefly met with in girls ; there is
usually a history that the art of walking was acquired with difficulty, and
at a later period than in other children. It is frequently associated with
imperfect development and flattening of the external condyle, with knock-
knee, and with unequal action of the quadriceps. It may occur on one or
both sides. The usual complaint is that in walking the patient suddenly
falls to the ground and suffers intense pain, both from the dislocation and
from the violent contact with the ground ; the knee-cap readily returns to
its normal situation when the leg is extended, but the joint may be swollen
and painful for a day or two. The dislocation occurs at irregular intervals,
and is quite beyond the control of the patient.

The following methods of operative treatment have", been practised : (1)
detaching the tubercle of the tibia, so as to allow of the insertion of the liga-
mentum patellae being displaced inwards ; (2) deepening the patellar groove
in the trochlear surface of the femur ; (3) tightening up the capsular
ligament along the inner side of the patella; (4) producing an artificial
bow-knee by supracondyloid osteotomy of the femur, as recommended by
Professor Chiene, and specially applicable in the female.

If there is knock-knee as well it should be corrected in the usual way
by Macewen's operation.

13. Diseases of Superior Tibio-Fibular Joint. — These are extremely rare
and of little practical interest. The author has observed infection of this
joint from a tuberculous focus in the head of the fibula ; the disease ulti-
mately spread to the knee by way of the popliteal bursa.

14. Diseases of the Bursal in the Region of the Knee. — The anatomical
situation of the bursse has been described in the article on "Bursse" in
vol. ii. Various types of acute bursitis are commonly observed in the pre-
patellar bursa ; acute infective forms result in the formation of a circum-
scribed abscess, or in a spreading cellulitis which may extend upwards into
the thigh and downwards into the leg, requiring prompt and energetic
treatment by multiple free incisions. The chronic or trade bursitis is
familiarly known as housemaid's knee.

Inflammation of the infrapatellar bursa is a very rare affection ; the
infective form is liable to spread to the knee-joint.

112

KNEE-JOINT, DISEASES OF

The bursa? in the popliteal space are chiefly liable to a condition in which
the sac of the bursa fills with fluid, that is to say, a hydrops, and it may be
difficult to differentiate this from the hernial pouchings of the synovial
membrane, known as synovial cysts, because the bursse liable to be affected
with hydrops may communicate with the knee-joint and share in its
hydrops, and yet the communication may be so narrow that one may not
be able to displace the fluid from the bursa into the joint. The bursa
between the inner head of the gastrocnemius and the semimembranosus
is the one most commonly affected with hydrops ; it forms a lax, fluctuating,
egg or sausage-shaped cyst at the inner side of the popliteal space. "When
the knee is extended and the popliteal fascia is on the stretch the swelling
becomes harder and less well defined, whereas in the flexed position it lends
itself better to digital examination. The treatment of the various forms of
bursitis is carried out on the same lines as in similar diseases elsewhere.
The quiescent hydrops of the semimembranosus bursa rarely gives rise to any
symptoms, and may therefore be left alone ; if treatment is required, the
most satisfactory procedure is to dissect it out.

15. Ganglia in the Region of the Knee. — These are chiefly met with in
working-men and athletes. The commoner variety develops on the outer
aspect of the joint, giving rise to a tumour about the size of a pigeon's egg
in the interval between the femur and tibia, and in front of the biceps
tendon ; when the limb is extended the tumour is hard and but slightly
prominent, in the flexed position it becomes more prominent and fluctuates.

The patient may ignore its existence, or may complain of stiffness, discom-
fort and difficulty in extending the limb completely ; the disability is greater
after working in the kneeling posture, or after football or tennis. If treatment
is required the tumour should be excised ; in doing so, some of the fibres of
the capsular ligament may require to be sacrificed, and the knee-joint may
be opened into. On section the tumour is found to be a multilocular cyst,
the spaces of which are filled with a colourless jelly rich in mucin. The
author has observed similar ganglia on the inner aspect of the knee, also in
the interval between the bones, and in front of the inner hamstring
tendons.

16. TUMOUKS IN THE PtEGION OF THE KNEE

Of the Bones.

Chondroma and osteoma.

Sarcoma.

Hydatids.

In the Popliteal Space.

Enlarged gland and chronic abscess.
Bursal swellings.
Synovial cysts.
Consolidated aneurysm.
Neuroma.

The cartilaginous exostosis is the commonest innocent tumour in
the region of the knee ; it may be the only one, or there may be
a large number scattered throughout the skeleton ; originally developing
from the epiphysial junction, the tumour in the case of the femur usually
projects on the outer or the inner side of the bone, and may attain a con-
siderable size ; in the case of the tibia it more often projects on the antero-
lateral aspect between the tubercle and the internal tuberosity, and grows
downwards parallel with the shaft. There may be some arrest of the growth
of the limb from interference with the epiphysial cartilages. The tumour
causes inconvenience by its bulk, or there may be a bursa over the convexity
which may become enlarged and sensitive.

As a rule these exostoses may be left alone, as they cease to grow when

KNEE-JOINT, DISEASES OF 113

the skeleton has attained maturity ; if they are causing suffering they are
easily removed ; a vertical incision is made through the soft parts, and the
neck of the tumour is cut through with a stout chisel.

Cystic tumours in the interior of the femur or tibia, of the nature of
liquefied chondromata, endotheliomata, or myeloid sarcomata, are of very rare
occurrence.

Sarcoma of the bones in the region of the knee-joint are comparatively
common, especially in children and young adults. Their general characters
have been already described with the " Diseases of Bone," in vol. i. We
may again refer to the great difficulty of diagnosis when they are met with
at an early stage, before the tumour element has become a prominent
feature, and before the advent of such pathognomonic symptoms as egg-shell
crackling, spontaneous fracture, and infection of the overlying soft parts.
Most difficulty is met with in relation to tumours of the lower end of the
femur, which sometimes resemble the chronic and especially the tuber-
culous forms of joint disease; the differential diagnosis has been already
discussed under this head.

Sarcoma of the upper end of the tibia is nearly always of the central
variety ; it is less likely to be mistaken for disease of the knee-joint than
for other chronic lesions of the upper end of the bone, e.g. tubercle, gumma,
Brodie's abscess, hydatid, etc.

Sarcoma of the upper end of the fibula is of the periosteal type, and
appears clinically as a rounded or flattened elastic swelling; practically
free from pain or tenderness ; the cutaneous veins are increased in number
and size over the tumour ; the movements of the knee-joint are intact, and
the patient is quite able to walk or run about. When the knee is flexed
the tumour may be felt to project towards the popliteal space. A tuber-
culous mass commencing to liquefy into a cold abscess is the only lesion
which at all resembles it. The treatment applicable to sarcomata in the
region of the knee has been described in the general article on " Diseases of
Bone," in vol. i.

Hydatids. — The ends of the bones forming the knee-joint are among
those most frequently affected with this rare disease ; the clinical features
resemble those of the more slowly-growing central sarcomata, e.g. deep-
seated pains and enlargement of the bone ; the swelling may be firm and
elastic, or may exhibit egg-shell crackling ; spontaneous fracture and
suppuration are likely complications.

Treatment consists in making an extensive opening into the bone and
clearing out the cysts from its interior ; the cavity is then stuffed or drained.
The eradication of the parasite must be thorough or the disease is liable to
relapse.

17. Paralysis of Muscles acting on the Knee-Joint and Paralytic Contrac-
ture.— Peripheral paralysis from injury or disease of the individual nerves,
e.g. the anterior crural, the great sciatic, are extremely rare. When the
extensor group of muscles is paralysed the disability is considerable, as the
patient is unable to bear any weight on the limb except in the position of
complete extension.

In infantile paralysis involving the lower extremity, the knee-joint may
be so unstable and wobbly that the patient may be unable to walk without
the assistance of a crutch ; artificial ankylosis of the joint is the most satis-
factory treatment. As a rule the paralysis is followed by the contraction of
certain groups of muscles and by deformity, of the kind usually called para-
lytic contracture ; the knee is usually flexed, and although the patient may
be able to increase the amount of flexion he is unable to extend the knee.
VOL. vi 8

114

KNEE-JOINT, INJURIES OF

Along with the flexion there may be a variable amount of genu valgum and
inversion of the thigh, especially in patients who have walked with a crutch.
The disability is usually aggravated by the addition of paralytic contracture
deformity at the ankle. As regards treatment, while a good deal of improve-
ment may follow upon division of the shortened structures and correc-
tion of the deformity, arthrodesis of the knee in the extended position yields
the best results in the majority of cases.

Paralytic genu recurvatum is a rare but very unsightly deformity result-
ing from infantile paralysis when it chiefly involves the extensor muscles
of the thigh ; the deformity is the result of the patient using the limb so
as to compensate for the muscular weakness. In taking a step forwards,
he swings the leg forwards so that when the foot touches the ground the
knee is hyperextended, this being the only position in which he is able to
bear his weight on the limb without the knee suddenly giving way under
him. The hyperextension becomes more and more pronounced as the liga-
ments and other structures in the ham gradually yield and stretch.

The treatment consists either in fixing the knee-joint by a suitable
apparatus or in performing arthrodesis.

LITERATURE. — In addition to that given under general article on diseases of joints :
Die specielle Tuberculose der Knochen und Geliiike : I. Das Kniegelenk, by Professor Kbnig
of Berlin. — A. G. Millee. "Tubercular Disease of Knee," Trans. Med.-Chir. Soc. Edin. 1889.

Injuries of the Knee-Joint

Injuries

Sprains .
Bruises .
Wounds .
Gunshot Wounds

114
115
116

116

Fractures in Vicinity op Knee-
Joint

Lower End of Femur

Tibia below Tuberosities .

From Compression op Tibia
through its Articular Sur-
face .....

Upper End of Fibula

Patella

Spontaneous Fractures .

117

118

118
119
119
121

Epiphysial Injuries

Separation of Lower Epiphysis
of Femur . . . .122

Separation of Upper Epiphysis
of Tibia . . . . 125

Separation of Upper Epiphysis
of Fibula . . . .125

Dislocations

Dislocation of Knee-Joint . 126
Dislocation of Patella . .127
Dislocation of Semilunar Car-
tilages . • . . .127
Other Intra - articular In-
juries ..... 129

Injuries

Sprains. — Sprain of the knee-joint is a common injury caused by a twist or
wrench of the joint. It is associated in the majority of cases with a varying
degree of tearing of ligaments and synovitis. In severe cases a sprain may
be accompanied by haemorrhage into the joint, rupture of tendon sheaths,
and displacement of tendons, or injury to a semilunar cartilage. Ligaments
may be wrenched from the bone and the synovial membrane may be torn.

Diagnosis of sprain is chiefly negative. Bony points should be carefully
examined to exclude fracture or separation of an epiphysis, especially that
of the lower end of the femur, which in children may easily be mistaken
for a sprain. Pain and tenderness is often most marked over the attach-
ments of ligaments. A certain diagnosis that the injury is nothing more
than a sprain may be rendered impossible at first by the swollen condition
of the joint.

KNEE-JOINT, INJUKIES OF 115

Prognosis. — After a sprain the joint is usually weak, and for some time,
often months, is not to be depended on for active work. In the severer
cases adhesions tend to form, and stiffness results which is troublesome to
overcome, and may result in a degree of permanent impairment of the joint
movements. Effusion may persist and become chronic. As a rule
haemorrhage into the joint is absorbed without ill results.

A joint once sprained is liable to subsequent attacks of synovitis
consequent on very slight injuries or over-exertion. For a year or two this
susceptibility may be a source of constant annoyance to the owner of the
joint.

Treatment. — Eest, elevation of the limb, and the application of a posterior
splint should be accompanied by either cold, in the form of an ice-bag, or
Leiter's coils, or hot fomentations. It is a question which is the better.
The sooner treatment is commenced after the accident the better is the
result obtained. In using heat the best method to adopt is to place the
knee at once over a bath or basin of hot water, and sponge it, keeping it
as hot as is bearable by the addition of more hot water from time to time.
This should be continued for half an hour, and then the limb wrapped in
a large quantity of cotton wool, and a bandage as firmly applied as is
consistent with comfort. Rest and pressure should be continued so long as
swelling and tenderness persist. If ligaments have been torn to any
extent this period of rest should be prolonged to three or four weeks to
allow of healing of the torn structures. If the effusion be very great
immediate aspiration may be performed before application of the bandages,
every care being taken to ensure asepsis. The subsequent treatment should
consist of massage of the limb, gradual movement of the joint, and the use
of a support to the knee when the patient commences to go about. Some
surgeons advise the immediate application of a plaster bandage, accompanied
at first by rest in bed and elevation of the limb, though later the patient
may go about on crutches. This bandage to be removed when sufficient
time has elapsed to allow of repair of the ligaments, and then massage
and movement commenced. A bandage or light leather knee-cap will be
necessary when the patient commences to walk. In the treatment of old
sprains the use of the Dowsing hot-air baths accompanied by massage and
electricity often yields very successful results. Manipulation and movement
of the joint under chloroform may be necessary to overcome adhesions within
the joint and neighbouring synovial sheaths.

Bruises. — Blows and crushes of the joint may cause severe damage
without the skin being torn. Synovitis, detachment of articular cartilages,
ligaments, or tendons, crushing and splitting of the ends of the bones,
haemorrhage into joint, and rupture of the main vessels may result. Slight
contusions may be followed by tuberculous disease, arrest of growth of limb
due to injury of epiphysial cartilage in the young, or a form of chronic
arthritis with lipping of articular edges, grating and creaking of the joint.

Severer crushes may be followed by sloughing of the skin, the crush
becoming compound, or gangrene of limb from injury to the vessels.
Suppuration is very prone to occur followed by necrosis of parts of the
bones, acute abscesses, and sequestrum formation, sometimes pyaemia ; haemor-
rhage into the joint may result in ultimate adhesions and ankylosis.

Treatment. — Where the skin remains intact even severe bruises are well
recovered from. The treatment consists in elevation and the careful
application of splints.

Where there is considerable inflammatory reaction leeching may give
excellent results. The ice-bag may be used unless the skin is much bruised,

116 KNEE-JOINT, INJUKIES OF

in which case it is better avoided owing to the risk of death of the
skin. If suppuration occur, free drainage should be provided, small
fragments removed, and continuous irrigation or immersion in a warm
boracic bath employed. Excellent results frequently follow this method of
treatment. In cases where the ends of the bones are implicated, or the
main vessels torn, amputation is necessary.

Wounds of Knee-Joint. — All wounds of the knee-joint are grave
injuries owing to the presence of the large synovial membrane and its
pouches, and to the risk of septic infection, the instrument causing the
injury being rarely aseptic. •

Symptoms. — The chief difficulty, especially in punctured wounds, is to
decide whether or not the joint has been opened. The escape of synovial
fluid is certain evidence of penetration of the joint. Fluid may, however,
come from a synovial sheath or a bursa, though not in the same amount.
If there be no escape of synovial fluid the rapid swelling of the joint is
a very suggestive sign. Where there is doubt great caution should be
exercised in the use of a probe. Frequently the instrument enters at a
distance from the joint and produces a more or less valvular wound, thus
preventing the ready escape of fluid.

In gunshot wounds the joint is usually unmistakably involved. Bullets
striking- the large and cancellous extremities of the bones in the neighbourhood
of the knee-joint frequently drill cleanly through them. In the past war in
S. Africa cases have been recorded in which the condyles of the femur have
been drilled through without fracture taking place. The patella is usually
drilled, but may be fractured, and numerous cases have occurred in which
the bullet has passed through the knee-joint and perforated the femur or tibia
as well. The small bore and the high velocity of the bullets are responsible
for this peculiarity.

The range appears to have little effect in determining the extent of the
injury. Hsemarthrosis is a frequent symptom, but the swelling usually sub-
sides rapidly. In the Chitral campaign, where bullets of larger calibre and
less velocity were used, the injuries were much more severe. A bullet strik-
ing the patella and femur produced extensive fracturing of the bones, and
sometimes the cavity of the knee-joint was converted into a mere bag of
comminuted fragments of bone. The upper end of the tibia is much more
liable to splinter than the lower end of the femur, and the fracture may
extend into the joint.

Treatment. — All wounds should be carefully cleansed with soft soap and
turpentine, and then washed with corrosive or biniodide of mercury lotion
1-1000 or 1-2000. A clean incised wound may be sutured at once. Eagged
edges should be trimmed, and if much bruising it is better not to aim at
immediate union.

In severe wounds and in gunshot wounds, accompanied by injury to
bones, the treatment used almost invariably to be amputation. The experi-
ence of the past war has been very different — the recoveries from gunshot
wounds of the knee being numerous and with useful limbs.

These excellent results have been due, not so much to the facilities for
antiseptic surgical practice, which was often very difficult to carry out effi-
ciently, but to the general favourable surroundings of the patients.

The after-treatment of wounds of knee-joint should consist in rest on a
splint until the wound is healed and any effusion has subsided, and then
gradual movement and light support of the knee.

Complications. — 1. Acute septic arthritis; the symptoms are rapid swell-
ing of the joint, with redness, heat, pain, oedema, and fever. If limb is not

KNEE-JOINT, INJUEIES OF 117

controlled the knee becomes flexed. Erosion of cartilage gives rise to
agonising pain when the joint is moved, and the characteristic starting
pains at night. Pus tends to burrow among the muscles, and secondary
abscesses and pyaemia may result. If sepsis is suspected the joint should
be aspirated, and if the fluid is becoming purulent the joint should be freely
incised on both sides and drained after irrigation with 1-2000 corrosive.
The pouches, especially that beneath the quadriceps, should be carefully
washed out and a tube inserted into each. Continuous irrigation is of
great value. Amputation may become necessary.

2. Impaired mobility or ankylosis will result from adhesions in severe
injuries, or after sepsis, in many cases but not in all.

3. Injury to, or tearing of the popliteal nerves from the instrument
causing wound, or from splintering of bone. These will require suture.

4. Injury to popliteal artery and resulting aneurysm may occur.

5. Osteomyelitis is a very rare complication.

Foreign Bodies. — Sometimes nothing can be felt, even on the most
careful examination. In these cases a skiagraph will often show the posi-
tion of the foreign body. It is often of great assistance to have a lateral
view of the joint as well as an antero-posterior.

Treatment. — A lateral incision will often be sufficient to reveal the
foreign body. If lodged between the condyles it may be brought into view
by alternately flexing and extending the joint, and thus enable one to remove
it with a sharp hook or forceps. Should this fail the patella will require to
be turned aside or sawn across to allow of a full view into the joint cavity.
The body frequently is found between the condyles, and may be attached to
the intercondyloid notch by dense fibrous tissue. To avoid having the
cicatrix adherent over the patella, and to have it well removed from possible
pressure in the act of kneeling, it is best to make a curved incision across
the knee with the convexity upward, the extremities being well over the
condyles, and the middle above the upper margin of the patella. A vertical
lateral incision may be converted into the more extensive one if required.
The joint should be closed without drainage, and such cases recover with
perfect movement if asepsis has been preserved.

Fractures in Vicinity of Knee-Joint

Fractures of lower end of Femur. — The varieties to be distinguished
are : (a) supracondyloid, (b) oblique and T-shaped fractures of the condyles,
(c) detachments of parts of the articular surface.

(a) Supracondyloid fractures may be transverse just above the condyles,
or oblique ; sometimes spiral, due to twisting of the bone ; when transverse
or oblique the displacement of the lower fragment is typical, the powerful
gastrocnemius tending to flex it toward the popliteal space, so that the
upper fragment overrides the lower. The knee-joint may be involved as
a result of this injury. A serious complication may be found in pressure
on or rupture of the popliteal vessels by the lower fragment when the
displacement is extreme, resulting in thrombosis of the artery or gangrene of
the leg.

Diagnosis. — The signs are, shortening of thigh, crepitus, abnormal
mobility and projection of the displaced fragment. If the knee-joint be
involved there will be effusion into it. Pulsation in the tibial vessels
should be sought for ; its absence renders the condition much more serious.

Treatment consists in giving an ansesthetic and reducing the displace-
ment by extension. If the fragments can be easily controlled the limb

118 KNEE-JOINT, INJUEIES OF

should be placed in a straight splint with extension. If the tendency to
displacement be well marked, the knee should be bent and the limb placed
on a double inclined plane, with extension in the line of the thigh, or a
Hodgen splint may be used. If the displacement persists, the tendo
Achillis should be divided.

The joint may be aspirated if much effusion of blood is present.
Massage and passive movement should be commenced in fourteen days, by
which time sufficient callus should be formed.

Injury to the popliteal artery may result in a traumatic aneurysm and
arrest of the circulation in the leg, in which case it will be necessary to
incise the popliteal space, turn out the clots, and ligature both ends of the
artery. The removal of the pressure of the clot may allow of a sufficient
collateral anastomosis through the articular branches to save the limb.
This anastomosis is not, however, good, because the blood must pass through
two sets of capillaries — from profunda and anastomotica — into the articulars,
and thence into the tibials. If, therefore, the leg still remains cold after
the pressure of the aneurysm has been removed, gangrene is imminent, and
amputation just above the seat of fracture is necessary.

Oblique or T-shaped Fractures of the Condyles. — Oblique fractures of
one or other condyle may occur from severe violence ; the fracture runs from
the intercondyloid notch obliquely upwards. Displacement is usually
slight, as the fragment remains attached to the lateral ligament.

In the T-shaped fracture the split between the condyles is more vertical,
and both are separated from the shaft.

Diagnosis is made by the recognition of lateral mobility and crepitus,
increase of width of the knee, pain on pressure about the condyles, effusion of
blood into the knee, and the presence sometimes of sharp projections of bone.

Treatment. — Is best treated in a slightly flexed position on a Hodgen
splint. Extension and elastic compression to the joint should be applied.
If necessary the joint may be aspirated first. Great care should be taken
to get the limb straight in putting up this form of fracture, as there is con-
siderable tendency to genu valgum or varum after such an injury. Early
massage, and in a fortnight passive movement, should be carried out to
avoid ankylosis.

Fractures of Farts of the Articular Surface. — Very rarely the attach-
ments of the lateral ligaments may be detached along with part of the
articular edge in dislocations of the knee.

Feactuee of Tibia below Tubeeosities. — Also a rare injury, and
results from direct violence as a rule, e.g. a kick. Indirect violence, such as
might lead to fracture of the lower end of femur, or a dislocation of the
knee, may be responsible for it. The line of fracture may be oblique, and
may enter knee-joint and cause synovitis.

Diagnosis depends chiefly on the increased width of the bone, tender-
ness on pressure, abnormal mobility, and crepitus. The use of an anaesthetic
or the X-rays will aid the diagnosis.

Treatment. — "Weight, extension, with the injured region left exposed to
allow of massage, and compression by a bandage. Any tendency to varus or
valgus should be watched for and corrected at once. After four weeks
plaster of Paris may be applied.

Feactuee from compression of Tibia through its Articular
Surface is caused by the forcible pressure of the tibia against one or other
of the femoral condyles in a fall from a height on to the feet, occurs in falls
from a dogcart, during mountaineering, or jumping off a bicycle.

There may be simply a fissure traversing the joint surface, but in bad

KNEE-JOINT, INJUKIES OF 119

cases the end of the tibia may be crushed into two or more fragments, be-
tween which the shaft is impacted.

The signs are great tenderness with increased width of upper end of
tibia, perhaps abnormal lateral mobility. If fracture involves only one-half
of tibial articular surface there may be a tendency to varus or valgus, the
former being more frequent as the inner tuberosity is more frequently in-
volved. There will always be haemorrhage into the joint. Subsequently
there is considerable synovitis and a tendency to arthritis deformans.

Treatment. — Weight extension with lateral traction, if necessary, to
correct the varus or valgus. Massage and passive movement should be
commenced as soon as swelling and pain have subsided.

Compound and comminuted fractures involving the knee-joint should be
treated by the removal of small loose fragments. When a tuberosity is
detached it should be wired. If asepsis be obtained good movement may
be expected.

Fbactuke of Upper End of the Fibula, usually due to a direct
kick, or fall on the outer side of the leg, may be produced by strong con-
traction of the biceps muscle. The fragment is not always displaced, and
the chief symptoms are pain on pressure and possibly crepitus. The
external popliteal nerve may be injured. If displacement is present the
best treatment is probably to wire the fragment in position, as it is not
easily controlled by splints ; otherwise retention on a splint for a fortnight
followed by a knee-cap will suffice.

Fracture of Patella is more common than dislocation, and occurs
chiefly in males between the ages of twenty and fifty. The patella owing
to its position is much exposed to injury.

Fracture may be from direct violence, such as a fall or a severe blow on
the knee. The resulting fracture is usually of a stellate form, the bone
being splintered in more or less radiating lines. Owing to the strong
aponeurosis in which the patella lies, the fragments as a rule remain close
together. If, however, the knee be forcibly bent after the bone has been
broken, extensive tearing of the aponeurosis takes place. Earely direct
violence may result in oblique, longitudinal, or transverse fracture.

Fracture from indirect violence is much more common,and is due to muscu-
lar action. It usually occurs when after stumbling or having missed a step.

It is brought about by the sudden violent contraction of the quadriceps
extensor in the effort to save a fall after stumbling or missing a step. At
the moment the effort is made the knee is bent, and the patella rests on the
edge of the condyles. The contracting muscle bends and then breaks the
patella across. The result is a transverse fracture, which may or may not
be across the centre of the bone. The aponeurosis and lateral ligaments are
usually considerably torn, allowing of a wide separation of the fragments.

There is much truth in the popular saying that " a drunken man in
falling seldom or never breaks his knee-cap," the explanation being that he
falls like a log, making no effort to save himself. Sometimes, as in the case
in which the patella is struck by a relatively soft object, such as a tennis
ball, the patellar reflex is probably one of the causes of transverse fracture.

Frequently the aponeurosis covering the patella ruptures at a different
level to the bone, and the flap resulting may fall and lie between the
fragments. To this fact, in addition to wide separation and tilting of the
fragments by the pressure of effusion, is ascribed the frequency of fibrous
union in cases of fractured patella, which are not treated by operation.

The Symptoms are very simple if fracture is through the middle of the bone,
and is attended with separation of the fragments. The bone being embedded

120 KNEE-JOINT, INJURIES OF

in the joint capsule, the injury involves opening into the joint cavity, and
extravasation of blood therein which may rapidly and completely fill the joint.

The signs are loss of power of extension of the leg, a more or less distinct
gap between the fragments, and lateral mobility of the fragments. The gap
is increased by bending the knee. In recent cases one may be able to bring
the fragments together and elicit crepitus. If only a small piece of the
patella is torn off, especially if the fibrous investment of the bone is fairly
intact, diagnosis may be more difficult.

Fractures from direct violence may be compound. In obscure cases a
skiagram will be of assistance.

The Prognosis depends on the kind and severity of fracture, whether
stellate or transverse, on the amount of separation of the fragments, and on
the method of treatment adopted. Fractures from direct violence give very
good results. Cases where there is separation treated by other means than
suture almost invariably result in fibrous union, which tends to yield. Those
treated by suture result in union, which is frequently bony, or if fibrous is
much closer and stronger. After fracture the strength and mobility of the
limb are often permanently diminished. The impairment in capacity for
work must depend to a considerable extent on the patient's occupation.
Persons with some light occupation, in which they chiefly sit at work, are
but slightly incapacitated. Those engaged in laborious occupations, in
which physical force is of value, will suffer a great deal. Even though the
power of extension be completely, and that of flexion almost completely
recovered from, still the knee-joint and lower limb are apt to remain weaker
and less fitted for active work. The causes of unfavourable results after
healing are attributed to (1) contraction of quadriceps ; (2) atrophy of this
muscle ; (3) effusion of blood into the knee-joint, causing separation of frag-
ments, and in rare cases organisation of clot and ankylosis ; (4) low degree of
vascularity of patella and its comparative lack of ability to form new bone ;
(5) interposition of bands of aponeurosis derived from the front of the bone
which favours ligamentous union, even if the fragments are kept close together.

Treatment. — 1. Non-operative Procedure. — The hip should be flexed and
knee fully extended to relax the quadriceps, and the limb placed on a
straight splint, which may be in the form of an inclined plane, or of felt or
poroplastic moulded to the back of the limb, and supported or slung to
continue the relaxation. If tension in the joint be great the effused blood
may be removed by aspiration. The fragments should then be brought
together, and the torn aponeurosis and clots displaced as far as possible by
rubbing the surfaces against each other. The limb should be fixed to the
splint, and the fragments kept approximated as nearly as possible by two
strips of plaster placed one above each fragment, the ends being crossed and
fixed to the splint. Another method is by means of a strip of plaster 8" x 3",
with one end curved to fit above the upper fragment. This is applied, and
two elastic bands are fixed to each corner of the plaster, and then stretched
on each side of the leg to be fixed to splint lower down. The plaster should
be held in position by the bandage fixing the thigh to the splint. The
quadriceps should be gently massaged daily, and occasionally a weak faradic
current may be applied. After eight weeks the patient may be permitted
to walk with crutches, a light splint or leather knee-cap being worn for
some months, massage, and gradually increasing passive and active move-
ment of the joint should be carried out daily. Fractures from direct
violence, with no displacement of the fragments, should be kept on a splint
for three to four weeks, and then passive movements commenced.

2. Operative Procedure. — (a) Malgaigne's hooks, which are now hardly

KNEE-JOINT, INJUEIES OF 121

ever used, are inserted into the fragments after preliminary puncture of the
skin, and then screwed together. The result is generally fibrous union.

(l>) Mayo Robson's method consists in the passage of two needles trans-
versely— one through the quadriceps, and the other through the liganientum
patellae, both close to the bone, and wiring the ends together.

(c) Twynam, by means of a special curved needle, passes subcutaneously
a suture of silk or silver wire round the margin of the fragments, through
the quadriceps and liganientum patellae. The fragments are placed in
contact, the encircling suture drawn tight, knotted, and cut short.

(d) Barker's method of subcutaneous suture is carried out as follows : —
A tenotomy knife is passed through skin and middle of ligamentum patellae
close to edge of lower fragment. A curved needle on a handle is passed
through this track and behind the two fragments, being brought through
quadriceps close to the edge of upper fragment to the skin. The skin is
incised on the needle, and the knife introduced so as to split the tendon verti-
cally between the needle and the edge of patella. The needle is threaded with
strong silver wire, and withdrawn with one end of the suture. The needle is
then passed between the skin and patella from the first puncture to the other,
threaded with the other end of the suture, and again withdrawn. The
fragments are approximated and rubbed together to remove clots, the blood
in the joint is squeezed out through one of the incisions, the suture is then
tied firmly, and the ends cut short. Passive movements may be commenced
in three or four days, and the patient should be able to walk in five or six
weeks. No splint should be used.

(e) Direct suture by opening the joint is the best procedure, so far as perfect
co-aptation is concerned. Must be done only under rigid aseptic conditions.
Is especially suited for cases which have not done well under treatment by
splints. If it is decided to employ this method in a recent fracture a few
days should be allowed to pass to permit the swelling to subside, and to enable
one to purify the skin. The fragments are best exposed by turning down a
flap, which done, the joint should be cleared of clots and dried. The frag-
ments should then be examined, and any drooping of aponeurosis over the
edges raised up. The fragments may be sutured in various ways ; silk, silk-
worm gut, or silver wire may be passed vertically round the fragments, or
they may be drilled in two places, and a double suture employed. The ends
of the wires should be twisted once or twice, and pressed level with the bone
surface. The torn edges of aponeurosis should be united with a few catgut
sutures. In old-standing cases the fractured ends should be sawn off before
the fragments are united. .

The result of such an operation is as a rule good, the patient being able
to bend the knee freely in two weeks, and able to walk in three to four
weeks. A knee-cap is unnecessary. Though the patella forms callus more
slowly than any other bone, union is usually bony. The risk of refracture
is comparatively slight.

Owing to unfortunate results from septic inoculation at the time of
operation that have occurred from time to time, and also to the very fair
results often obtained from non-operative treatment, wiring the fragments
is far from becoming the routine practice. No other method gives such
complete approximation of fragments and such firm union, but whether
risk of operation is justified is still an open question.

Spontaneous fractures are those which occur in a bone which is
diseased ; the bone, being weakened by the presence of the disease, breaks
on the application of very slight violence.

The chief causes which lead to spontaneous fractures are : —

122 KNEE-JOINT, INJUBIES OF

1. Atrophy of bone from age, disease, thinning from pressure of an aneurysm,
or simple growth, from tabes, general paralysis, and chronic brain diseases.

2. Fragilitas ossium, a fragile condition of bones, not associated with
obvious atrophy, and often with a hereditary history.

3. Inflammation of bone, with subsequent necroses, abscess, or caries, of
pyogenic, tuberculous, or syphilitic origin.

4. Eickets. Ossification is irregular and feeble, resulting bone being
spongy and fragile. Union is much delayed, and may not occur until disease
is almost cured.

5. Osteomalacia. The change consists in decalcification of bone and
subsequent absorption of part of the constituents by the marrow. Bone
gets thinner and thinner till it becomes a mere shell and disappears alto-
gether, being replaced by the marrow.

6. New growths. Of simple tumours, the chondroma is the only one
that ever results in fracture. Sarcoma, which is usually primary, and
carcinoma, which is usually secondary, are much more frequent causes of
spontaneous fracture. A hydatid cyst may be responsible for the fracture.
(Euptureof ligamentum patellse and quadriceps, vide "Muscles and Tendons.")

Epiphysial Injuries

Separation of the lower epiphysis of the femur results from extreme
direct violence, as the passage of a wheel over the lower end of the femur,
and from indirect violence, giving rise to over-extension of the knee, together
with violent twisting and traction on the leg, as when it is entangled in the
spokes of a wheel in motion, and is carried round by it. This is the common
mode of production (Hutchinson, jun., Barnard). Lateral flexion or a force
applied in a lateral direction is best calculated to produce a separation of the
epiphysis (Henry Morris). In young children a slight fall may cause the
injury, especially if they are the subjects of some disease, e.g. syphilis,
rickets, tubercle. It is sometimes met with in railway and lift accidents.

The majority of cases are met with in children and young adults between
seven and fourteen years of age, although, theoretically, it may occur up to the
end of the twentieth year, i.e. before complete bony consolidation between
the diaphysis and the epiphysis has taken place. It is nearly always in boys.

In partial separation the line of cleavage between the epiphysis and
diaphysis is incomplete, the periosteal sheath is intact, and there is no dis-
placement. With complete separation the line of cleavage passes right
across the bone between the epiphysis and diaphysis. This may be simple
or compound.

Simple without Displacement. — In this condition the periosteal sheath is
usually untorn, the epiphysis being merely loosened. If, however, the peri-
osteum is torn the synovial membrane will be injured (for the epiphysis in-
cludes the whole articular surface), and acute synovitis of or effusion of
blood into the knee-joint will follow. The breadth of the femur and the
strength of the periosteum lessen the occurrence of displacement. There
is swelling about the joint, pain on attempting to move the limb, and tender-
ness along the epiphysial line.

Simple with Displacement. — In this variety the thin posterior periosteum
is perforated by the end of the diaphysis, which projects beneath the skin
to one or other side of the popliteal space, usually the outer. The periosteal
sheath is strongest on the front of the femur, and this band is rarely torn,
hence, when displaced, the epiphysis is carried forwards, taking with it the
tibia, to which it is attached by the popliteus and the strong crucial liga-

KNEE-JOINT, INJUKIES OF 123

inents, at the same time it is drawn upwards and inwards by the quadri-
ceps and adductors, and rotated backwards by the strong gastrocnemius, the
two heads of which are in part attached to the epiphysis. The fractured
end of the diaphysis is convex, and that of the epiphysial cartilage, which
usually remains attached to the epiphysis, is concave, and when reduced it is
not easy to displace them. If, however, the anterior band of periosteum is
torn the epiphysis is displaced backwards ; it is then difficult to keep in
position after reduction.

Symptoms. — There is marked deformity about the joint, increased girth
around the knee, and shortening of the limb from two to four inches. Great
swelling and ecchymosis in the popliteal space soon develop, with effusion
into the knee-joint of extravasated blood and synovial fluid. The broad
lower end of the diaphysis is felt at the outer side of the popliteal space. It
does not move with the leg when the latter is moved laterally. The epi-
physis is felt in front and to the inner side of the displaced diaphysis, and it
moves with the leg. Soft cartilaginous crepitus may be felt when the two
ends of the bone are in contact. There is abnormal mobility with hyper-
extension of the leg on the thigh, readily obtained under an anaesthetic.

Compound Separation. — With very severe injury the lower end of the
diaphysis is forced through the skin, and projects to one or other side of the
popliteal space, usually the outer.

Immediate Complications. — Separation may be complicated by a fracture
of the diaphysis or an intercondyloid fracture of the epiphysis, or one or
other condyle may be broken off, or a fracture of the upper end of the tibia.
When there is displacement the popliteal vein may be pressed upon, pro-
ducing oedema of the leg, and subsequent haemorrhage from ulceration,
or it may be wounded, giving rise to extravasation of blood into the
surrounding tissues. If the artery is compressed the injured limb will be
colder than its fellow, if wounded an aneurysm will form ; when 'completely
ruptured the pulse will be absent in the dorsalis pedis and the posterior
tibial arteries, and gangrene will set in. The popliteal nerves may be
pressed upon, producing pain in the leg and foot, or one or other nerve com-
pletely torn across.

Later Complications. — The vascular growing epiphysial cartilage when
damaged is liable to be the starting-point of tuberculous disease or acute
infective osteomyelitis. When the injury is compound, suppuration of the
wound with acute periostitis and necrosis (and suppurative arthritis)
accompanied by septic phlebitis and pyaemia frequently result. After
union has taken place there may be limited flexion at the knee from incom-
plete reduction of the deformity and permanent hyperextension ; fibrous or
bony ankylosis, especially if there was previous suppuration in the joint ;
shortening of the femur from impaired growth, and premature ossification
of the epiphysial disc, with secondary spinal curvature.

Diagnosis. — A partial separation is not easily distinguished from a
contusion of the lone; tenderness localised along the epiphysial line is in
favour of separation. In complete separation it may be necessary to
administer an anaesthetic in order to make out the true nature of the
injury. " Sometimes the displacement is so slight that the injury may easily
escape notice, or be mistaken for a traumatic synovitis " (Howard Marsh).

From a dislocation of the knee make out the exact relation between the
patella and the head of the tibia and fibula, also the movements in the joint.
Note the abnormal mobility. Dislocation of the knee is rare in young
subjects, and the joint is usually stiff and fixed, flexion and extension being
difficult — a skiagram will settle the difficulty.

124 KNEE-JOINT, INJUEIES OF

Sujpracondyloid fracture is rare in children, and the lower end of the
upper fragment is more pointed and oblique, and it is more distant
from the joint. The characteristic soft cartilaginous crepitus is patho-
gnomonic of separation if it be present. In favour of separation we have
the age of the patient as a guide, the absence of obliquity of the fragments,
the nearness of the fracture to the joint, the smoothness of the fragments,
and the great difficulty in effecting reduction.

Prognosis. — This is a very serious injury. It is attended when com-
pound by a high mortality from shock and pyaemia. The ultimate result,
however, in most cases that recover is good.

Treatment. — The following is advocated by Hutchinson, jun., and
Harold Barnard : —

Reduction. — " Under complete anaesthesia an assistant makes steady but
strong traction on the tibia in the line of the limb. This overcomes the
upward pull of the quadriceps extensor and brings the epiphysis down to
the line of the separation.

"The operator then clasps his hands beneath the lower part of the thigh
and draws it steadily upwards, gradually flexing completely the knee and
hip joints, while the assistant still keeps up the traction on the leg.

" This manoeuvre causes the epiphysis to move back upon the fractured
surface of the diaphysis until it has reached its normal position, and further
movement is prevented by the periosteum coming into contact with the
anterior surface.

" A bandage is then applied around the thigh and ankle, fixing the knee
at an angle of about 60°.

" The limb is laid on its outer side on a pillow and an ice-bag applied to
the front of the knee to limit the effusion. This position is maintained for
a fortnight.

" After fourteen days the limb can be extended under gas if necessary,
and put up in plaster in a position about 30° short of the straight line, or it
may be put on a Maclntyre splint and gradually extended. The plaster
remains on from a fortnight to three weeks, and a little massage restores
movement."

They conclude " that in extended position of the knee, even with an
anaesthetic, reduction of the fragment is very difficult if not impossible.

" With method of full flexion reduction is always easy, the treatment is
short, and it is the rule to obtain perfect movement in the knee without
shortening or deformity of the leg."

Aspirate the joint if there be much effusion into it, and apply elastic
pressure by means of a bandage.

"When compound the greatest care must be taken to procure asepsis.
The adjacent skin and the projecting diaphysis must be thoroughly cleansed
with soft soap and water, next with spirit, and lastly swabbed with and
the wound syringed out with 1 in 2000 perchloride or biniodide of mer-
cury, and an antiseptic dressing applied.

The wound may be completely closed, or a drainage-tube left in. A
Hodgen splint will be found most convenient for redressing the wound,
should this become necessary, without removing the apparatus. It may be
necessary to resect the end of the diaphysis in order to effect reduction ;
this is rarely required in simple displacement.

Ligature of the popliteal artery or vein, or both, may be necessary to
control haemorrhage. When gangrene occurs the thigh must be amputated
through its lower third, but only after all efforts to save the limb has failed.
Should suppurative arthritis supervene, the joint must be freely laid open

KNEE-JOINT, INJUEIES OF 125

on each side of the patella and drained. Amputation for pyaemia may
become a necessity later.

Sepaeation of Uppee Epiphysis of Tibia is rare, but its possible
occurrence must be remembered in any case of severe injury of the knee-
joint in a child. Its rarity is probably due to the fact that the liganientum
patellae, internal lateral ligament, and semimembranosus tendon, are inserted
partly into epiphyses and partly into diaphyses, thus strengthening their
relations.

Complete separation of upper epiphysis is usually the result of a violent
wrench of the leg, and is most liable to occur between 12 and 16 years of age.

Signs are abnormal mobility, cartilaginous crepitus, and displacement,
which is slight and consists of overriding of the epiphysis usually forward,
but occasionally inward and outward. Effusion into the knee-joint almost
invariably occurs.

Diagnosis. — Free movement of joint which is present in separation of
epiphysis serves to distinguish it from dislocation of the knee, which more-
over hardly ever occurs in childhood.

Mobility at epiphysial level below the articulation is conclusive. When
little or no displacement exists it may be mistaken for a sprain.

Prognosis. — Good union, usually osseous, follows. Ankylosis from
synovitis or suppuration in the knee-joint. Deformity may occur from
incomplete or non-reduction. Premature arrest of growth as a result of this
injury is rare, when it does occur the fibula is bowed out.

Treatment. — Any displacement present should be remedied by flexing
the knee and manipulation. Under an anaesthetic. When there has been little
or no displacement, the limb may be put up in plaster of Paris at once, or
lateral and posterior splints followed by plaster after two or three weeks.
Where much displacement has existed the better position is probably that
of flexion on a Macintyre or Hodgen splint. Primary amputation is only
necessary when the injury is compound and accompanied by severe
laceration of the soft parts. Secondary amputation may be called for by
gangrene or suppuration in the joint.

Sepaeation of Tubeecle of Tibia. — The epiphysis includes the
tubercle of the tibia, which is frequently developed from a separate
centre, and may be torn off by a violent contraction of the quadriceps.

Separation of the tubercle occurs when springing from the ground, as in
vaulting ; the commonest time of life is between 16 and 20 years. It
may be mistaken for fracture of the patella. The fragment is drawn up by the
quadriceps, and is freely movable in all directions. Active extension is
impossible. Blood may be effused into the knee-joint ; the fragment should
be fixed in position by a steel peg ; good union and use of limb result.

Sepaeation of the Uppee Epiphysis of the Fibula usually takes
place before its union with the diaphysis, and between the ages of 7
and 14, but it may occur after. Frequently its detachment accompanies
that of the upper tibial epiphysis.

This injury may result from indirect violence, such as forcible contraction
of the biceps while the knee is in a flexed position, or from direct violence, it
having occurred while a case of knock-knee was being straightened.

The prominent symptom is pain on pressure over the head of the fibula.
The fragment, which is readily movable, can be felt on the outer side of the
knee-joint, being displaced upwards by the biceps which is inserted into it.
The external popliteal nerve is liable to injury, giving rise to pain along its
distribution, and partial or complete paralysis of the peronei and extensor
muscles.

126 KNEE-JOINT, INJTJEIES OF

The diagnosis depends chiefly on the age of the patient and the extreme
mobility of the fragment. There may, however, be difficulty in distinguish-
ing it from a sprain, especially if severe bruising be present, in which
case a skiagram would be of assistance.

The treatment consists in the reduction of any displacement, and putting
up the limb in the flexed position, to relax the traction of the biceps on the
fragment. Massage of the joint should be commenced on the day following
the injury, and passive movements in 7 to 14 days.

Dislocations

Dislocations of the Knee-Joint are of very rare occurrence, and when met
with are due to extreme violence. Are found in machinery accidents, where
the leg has been violently twisted or wrenched, the thigh often being more
or less fixed ; also when men have fallen from a height.

The varieties of complete dislocation are — -forwards, occurring during hyper-
extension of the leg, the head of the tibia lying in front of the condyles and
drawn upwards sometimes as much as four inches; backwards, usually
due to violence to front of leg or back of thigh, the head of the tibia resting
behind the condyles. In both these forms the soft parts are extensively torn.

Incomplete dislocations are not likely to occur, and may be forwards,
backwards, laterally, or oblique. In this group the articular surfaces are
still partly in contact, and there is less destruction of soft structures.

Dislocation may occur laterally, combined with rotation of the leg on its
long axis, usually outward.

The soft parts suffer very severely in complete dislocations, the lateral
and crucial ligaments being extensively torn especially in the anterior and
posterior varieties. The hamstring muscles may be torn across, and injury
or rupture of the popliteal vessels and nerves may lead to gangrene of the
leg. The dislocation is frequently compound.

Mr. Eames in the Brit. Med. Jour., April 21, 1900, mentions five cases of
complete forward dislocation of knee all occurring at the same time, and
caused by a fall down the shaft of a mine ; and describes the appearances.
The following were prominent signs : —

Great deformity.

Condyles of femur prominent and projecting back.

The skin behind joint on the point of bursting.

The skin of popliteal space may be torn across without opening joint cavity.

Head of tibia and fibula on anterior surface of femur and drawn up
2 inches.

A varying amount of effusion and extensive ecchymosis.

A fracture of tibia or femur near joint may accompany dislocation.

Eeduction as a rule is easily accomplished under an anaesthetic by com-
bined traction and direct pressure.

Treatment. — The limb should be placed in a flexed position on a splint
or simply on pillows, arranging the limb in a position of greatest comfort.
Hot anodyne fomentations or ice-bags should then be applied until the
synovitis and extravasation have disappeared, which usually takes place in
eight to fourteen days. During this time the toes should be watched for
any sign of gangrene. Then a well-fitting leather knee-cap, extending
well above and below the joint, should be fitted on, and at the same time
gentle massage and passive movements commenced and continued daily.
Any return of synovitis and pain would necessitate a cessation of massage
until it subsided. After three to five weeks active movement may be

KNEE-JOINT, INJUEIES OF 127

gradually carried out. The splint should be worn for five or six months
or longer, the recovery of full strength in the limb being often long post-
poned. Eecovery may be accompanied by persistent oedema and eczema of
foot and leg. Compound dislocations and. those cases where gangrene
threatens may require amputation.

Spontaneous Recurrent Dislocation of the Knee-Joint. — This very rare
condition may be met with in infants. Dr. J. W. Ballantyne records a case in
which the child by simple pressure of one leg on the other could slip the
knee in and out laterally. A retentive apparatus was applied, and at six-
teen months the child could walk well and had no tendency to dislocation.
The condition is ascribed to congenital laxity of capsular and other liga-
mentous structures.

Pathological Dislocations occur in connection with advanced disease of the
knee-joint, the head of the tibia commonly passing backward and outward.

Congenital fixed Dislocations may be met with, and are associated with
rudimentary development or absence of the patella, or with obvious deformi-
ties of the articular surfaces of the femur and tibia.

Dislocation of Patella. — The patella is a sesamoid bone developed
in the quadriceps tendon, and is not firmly fixed at the sides. Dislocation,
which is rare, appears frequently to depend on some congenital defect in the
patella or femur, especially of the external, condyle, and usually takes place
to the outer side, on account of the patella resting more on the outer than
inner condyle, more especially if there be a tendency to knock-knee. The
dislocation is incomplete when the joint surfaces remain in contact, and
complete when the patella rests wholly on the outer surface of the condyle,
the edge or one or other of the surfaces being in contact with the condyle.
The dislocation may occur when the knee is extended, from strong contrac-
tion of the quadriceps causing the patella to glide directly over the outer con-
dyle, or during flexion from a blow on the inner side of the bone, the force
causing the patella to slide laterally in the groove between the femur and
tibia. Vertical dislocation consists in the rotation of the patella on its
vertical axis through an angle of 90°, so that one or other border rests in
the groove between the condyles. It is described as inward or outward
according as the cartilaginous surface of the patella is directed to the inner
or outer side of the joint. It is usually due to direct violence, though occa-
sionally, to muscular action. The inward variety is perhaps the more com-
mon. The bone may be twisted completely round, the articular surface
becoming anterior.

Diagnosis is usually easy, except perhaps in the rare condition of a
complete rotation of the bone.

Treatment. — Keduction as a rule readily effected by direct pressure after
relaxation of the quadriceps, by extending the knee and flexing the hip.
There may, however, be considerable difficulty in vertical dislocations.
After reduction a leather knee-cap should be worn well padded over external
condyle to prevent return of the dislocation. Operative treatment has
until lately been as a rule unsuccessful. Eecently mooring of the patella to
the inner side of the joint after division of the capsule on the outer side has
been followed by permanent success.

Dislocation of the Semilunar Cartilages. — Of the two cartilages the
internal is displaced twice as often as the external, and this is ascribed to
the following facts : — (a) That it is more firmly fixed than the external ;
(b) that a greater degree of rotation outward is possible, thus greater strain
can be brought to bear on its attachments ; (c) that the ordinary position
of the foot and leg lends itself to a greater liability to the production of out-

128 KNEE-JOINT, INJUEIES OF

ward rotation. Usually the .anterior attachment is torn, very rarely is the
cartilage completely detached or divided.

Production. — The injury is produced hy strong rotation of the lower end
of the femur when the knee-joint is bent and the tibia fixed, as when play-
ing a stroke at golf. Less frequently violent rotation of the tibia with
the femur fixed may result in displacement of a cartilage.

The cartilages move with the tibia in flexion and extension. In rotation
the tibia rotates beneath the cartilages, one or other being fixed.

During external rotation the external cartilage is fixed, and the internal
is apt to slip through the gradually increasing gap that is formed between
the tibia and the internal condyle of the femur.

The reverse occurs during internal rotation, but the external cartilage
being smaller, rounder, and more mobile than the internal, is less frequently
nipped between the bones when it slides into the gap.

This injury rarely occurs in a perfectly normal joint, being commonest
among those whose knee-joints are liable to have great strains thrown
suddenly upon them, such as football players.

Symptoms and Diagnosis. — After a twist of the leg there is sudden and
intense pain in the knee, often causing the patient to fall, with the joint fixed
in the flexed position. The knee rapidly becomes swollen, and on movement
being attempted the joint locks on extension, but can be flexed quite freely.
On extension the pain is increased, and the patient may feel that something
has become " jammed " in the knee. There is pain on pressure over the
joint line, and a projection is often felt which may be slightly movable. In
old-standing cases a choking may be felt on flexing and extending the joint.
If the detached end of the cartilage remains in the centre of the joint a
depression may be felt in the position of the cartilage, but the diagnosis of
this variety from a loose body presents considerable difficulty, especially if
there be much effusion.

Treatment. — In recent cases the cartilage should be replaced under an
anaesthetic if necessary. The procedure consists in flexing the knee com-
pletely, and then rotating the leg inwards or outwards according as the
internal or external cartilage respectively be displaced. While rotation is
maintained suddenly extend the leg, at the same time press the projecting
edge of the cartilage into the joint. After reduction rest on a splint and
elastic pressure are necessary. If the patient will permit, a plaster of Paris
case should now be applied, and the limb used as little as possible for several
weeks. This method, which gives the best chance of cure short of opera-
tion, is^rarely tolerated, and one has then to resort to a knee-cap to control the
movements of the knee as much as possible while allowing the patient to
go about. He should be warned to avoid any rotating movement of the
limb, walking with his toes in if the internal cartilage has been affected, and
out if the external. The knee-cap should be worn for three or four months.

Eecurrence is frequent from slight twists, and subsequently the car-
tilage is apt to slip out on the slightest provocation, thus interfering with an
active life. These are the cases for operative interference. An apparatus such
as Ernst's may be tried, but it is often very irksome and not always efficient.

The operative procedure may consist in either suture or removal of the
cartilage. The results of both are about equal, though probably removal is
the better, because a cartilage which has been sutured may get loose again.
Either operation may be performed through an incision over the joint line
on one or other side, according to the cartilage affected. The incision
extends between the ligamentum patellar and the internal lateral ligament
for the internal cartilage, and between the ligamentum and biceps tendon for

LABOUK 129

the external. The line of this incision in the capsule should be above the posi-
tion of the cartilage. The detached portion of cartilage which may be doubled
over is either placed in position and stitched to the fibrous capsule with catgut,
or removed. It is advisable to explore joint for a possible loose body at the
same time. The incision should be completely closed in layers. After-treat-
ment consists in controlling the joint for five or six weeks, at first in bed
with a posterior splint. When the wound has healed, use plaster of Paris or
a moulded poroplastic splint. At the end of four weeks, movements should
be commenced, and the patient gradually allowed to walk with a bandage on
the knee. Longer confinement is necessary after suture than after removal.

Detachment of part of articular cartilage from the femur is an injury
that may occur as the result of very slight violence. During flexion of the
knee it is possible to produce a certain amount of internal and external rota-
tion, and also some abduction and adduction, the knee-joint not being a
simple hinge. If, when the knee is bent, the bones are pressed together with
a lateral twisting, a portion of cartilage with spongy bone attached may be
forced off the femur. This portion may become completely loosened, and
form a foreign body in the joint, or may remain hanging as a loose body. In
either case it should be removed.

Rupture of posterior crucial ligament may occur as the result of a violent
blow on the anterior surface of the head of the tibia. The injury is followed
by synovitis and subsequent weakness of the knee. On examination the
head of the tibia can be slightly displaced backward into the popliteal space,
when the knee is bent at right angles and the foot steady on the ground.
For such a condition supporting apparatus should be worn for some months.

LITERATURE. — Fractures and Dislocations : 1. Helferich. Transl. by J. Hutchinson,
jun., New Sydenham Society. — 2. Astley Cooper. Fractures and Dislocations. — 3. Barker.
"Old Fractures of the Patella," Lancet, April 1898. — Epiphyses: 4. Poland. Traumatic
Separation of the Epiphyses. — 5. Hutchinson" and Harold Barnard. Trans. Med.-Chir.
Soc. vol. lxxxii. p. 77 ; also Lancet, 1899, vol. i. p. 1275.

Knock-Knee. See Deformities.
Kopftetanus. See Tetanus.
Kyphosis. See Spine.

Labium. See Vulva; Generation, Female Organs of.
Labour. — This will be described in the following sections : —

A. PHYSIOLOGICAL SECTION.
4. Management.

1. Physiology.

2. Progress and Duration.

3. Diagnosis and Mechanism

5. Labour in Multiple Pregnancy.

B. PATHOLOGICAL SECTION.

9. Retention of Placenta.

6. Precipitate and Prolonged

Labour.

7. Faults in the Passenger.

8. Accidental Complications

affecting Child only.

See also Pregnancy.

VOL. VI

10. Post-Partum Haemorrhage.

11. Injuries during Labour.

130 LABOUE, PHYSIOLOGY OF

1. Definition . . . .130

2. Causes of . . . .130

3. Difficulties of . .130

4. Stages 131

5. Factors —

(1) Poivers .... 131
General Description . 132
Action in various Stages 132

PHYSIOLOGICAL SECTION
Physiology of Labour

(2) Passages . . . 137
Hard and soft . . 137

(3) Passenger . . 139

(a) As a ivliole . .139

(b) The Foetal Head . 141

Relation of Passenger to

Passages . . . .141

Laboue may be defined as the separation and expulsion of the contents
of the gravid uterus, and is the physiological termination of pregnancy.

Causes of Labour. — The normal period of human gestation is prob-
ably 273 days, as evidenced by the statistical records of Leuchardt and
Leuwenwardt ; and the period of expulsion is conveniently calculated to
occur at the tenth menstrual period missed, or 280 days from the first day
of the last period. As is well known this date is by no means exact, as it is
impossible to determine in most cases the date of fertilisation of the ovum.

The reason why labour should occur at a specific time has been attempted
to be explained by many elaborate theories, each and all of which can be
met by insuperable objections, so it must still be considered as one of nature's
many mysterious secrets.

The theories advanced may to some extent explain the causation of
labour, but give no clue to its onset at a given time. Thus the researches
of Friedlander, Leopold, and Kundrat have demonstrated that the penetration
of multinucleated cells into the placental sinuses during the later months
of pregnancy lead to coagulation of the blood, and to the formation of young
connective tissue which obliterates the sinuses, and thus tends to increase
the amount of venous blood in the remaining active portion of the placenta,
which causes irritation and uterine contraction.

Brown-Sequard has tried to show that the excess of C02 circulating in
the veins of the gravid uterus, acts in a like manner.

Others assert that labour is induced by a fatty degeneration of the decidua
vera which predisposes to separation of the ovum and its subsequent expulsion,
while some authors consider that there is an increasing irritability of the
uterus with strengthening contractions, which acquire a special strength at
the tenth menstrual period missed, and cause separation and expulsion.

Doubtless there is much that is true in many of the theories advanced,
and probably several acting in unison may account for the onset of labour,
but it is needless to say that none give even the slightest evidence of why
it normally occurs at a given time. Natural selection seems alone to direct
us on reasonable lines. Children born before this period are puny and ill
able to lead an independent existence ; while children born later are so
large that their expulsion has incurred risks both for the mother and
themselves. By a process of heredity it will be evident that the survivor
of the fittest, or the majority of survivors, will be born on the 273rd day of
gestation, and will thus develop and fix a period which will represent the
habitual period of human gestation, or in other words assure the onset of
labour at a given time.

Difficulties of. — In the human female labour is an extremely finely
balanced complex process, and thus as a rule requires many hours for its
completion ; the smallest hitch in the normal mechanism tends towards,
indefinite delay and serious complications.

LABOUE, PHYSIOLOGY OF 131

The difficulty of labour in women as compared with the lower animals
is mainly to be accounted for by the difference in the pelvis and pelvic
floor necessitated by the erect posture, although at the same time the com-
paratively large size of the foetal head must also be taken into account.
As will be noted upon the description of the factors of labour, the passages
through which the ovum has to pass are curved and irregular in shape,
while the pelvic soft parts or floor are thick and compact to afford support
to the abdominal and pelvic viscera. In the lower animals, on the other
hand, the parturient canal is straight and regular, while the pelvic soft
parts are lax and thin. If proof were wanting of the difficult nature of
labour in woman, it is to be found in the marked thickness of the uterine
wall as compared with that of the lower animals, which is evidence of the
greater force required for the expulsion of the contents. The difficulties and
dangers of labour vary greatly in different types of the human race, and it
may be generally stated that the higher the grade the more difficult does
the process tend to become. This is probably due to the coexistent increase
in the size of the fcetal head dependent upon intellectual development.
The higher social grades of the same type seem also to have more difficult
labour, as evidenced by the higher mortality ; this, though perhaps due to a
slight extent to a similar cause, is doubtless exaggerated by the want of
physical development. The expulsion of male children, from their larger
size, is more difficult and dangerous than female children, the mortality to
the mother being about 40 per cent greater. As is natural to expect, first
labours are more difficult than subsequent ones, from the want of previous
dilatation of the canal.

Stages. — For the sake of description the period of labour is differ-
entiated into three stages : — ■

(1) The stage of preparation, from the commencement of pains till the
full dilatation of the cervix, or in other words till the complete canalisation
of the genital canal (1st stage).

(2) The stage of expulsion of the child, from the full dilatation of the
cervix till the birth of the child (2nd stage).

(3) The stage of separation and expulsion of the placenta and mem-
branes, from the birth of the child till the birth of the secundines (3rd
stage).

Factors of Labour

Embraced in the process we have to consider three factors, viz. : — The
powers, the passages, and the passenger. The powers are threefold : (1)
the uterine contractions, so called primary powers ; (2) voluntary
muscles, specially those of the abdomen, so called secondary powers ; and (3)
the weight of the ovum.

Primary Powers, or Uterine Contractions. — These must be looked upon
as by far the most important factor in expulsion, in so far as they alone are
able to complete the process as evidenced in cases of paraplegia and com-
plete anaesthesia. In their action they are intermittent, each contraction
lasts for a period of from thirty to a hundred seconds, with a varying
interval which is most regularly marked in the second stage. By means of
this intermittency, exhaustion of the mother is prevented, the placental
circulation is not embarrassed, and accommodation of the passenger to the
passages is favoured. Uterine contractions are purely involuntary, although
they may be influenced mentally, — a point of importance in the manage-
ment of labour, in so far as we know that encouragement stimulates, while
on the other hand depression tends to diminish their action.

132

LABOUK, PHYSIOLOGY OF

Doubtless the centre of nervous stimulus lies in the sympathetic
ganglia, although a spinal centre has been described in the lumbar enlarge-
ment of the cord and a cerebral centre in the medulla. It has been stated
that the intermittency is due to paralysis of the terminal nerve filaments
in the uterine wall, induced by contraction of the uterus, and probably
influenced by the resulting ansemia. The contractions are usually associ-
ated with painful sensations, hence the common expression of " pains "
applied to them. These painful sensations vary in the different stages of
labour. In the first stage they are of a cutting nature, while in the second
stage they may be described as of a bearing down, tearing character.
Along with the temporary contractions of the uterine walls and their
intervening relaxation we have at the same time a permanent shortening of
the muscular fibres known as retraction. By this means not only are the
individual fibres permanently shortened, but also there is a redistribution
of their arrangement.

We have thus in the action of the primary powers a double effect : (1)
a temporary marked shortening of the individual fibres, "contraction"; and
(2) a permanent slighter diminution in length, " retraction."
Uterine contractions are not peristaltic.

The, Secondary Powers. — As has already been stated, these are mainly
supplied by the contractions of the abdominal muscles and diaphragm.
They not only are of value in assisting the primary powers in their ex-
pulsive efforts, but also are beneficial in preventing the effects of excessive
retraction, and maintaining the long axis of the uterus in the axis of the
pelvic brim. Though not absolutely essential, their absence or impaired
action seriously delays the completion of labour, a point of great practical
importance in reference to the question of anaesthesia during parturition.
To a great extent the secondary powers are reflexly stimulated to act, but
at the same time their force is markedly influenced by mental control, the
parturient being able to voluntarily assist in the expulsive efforts.

The Weight of the Viscera. — This is a factor of very minor importance,
but may have a slight effect when the patient is in the erect posture by

assisting dilatation of the cervix. Thus the par-
turient should be encouraged to walk about during
the first stage.

Action of the Powers in the Different Stages
of Labour. — During the first stage the uterus is
practically alone concerned in the dilatation of
the cervix, and for a clear conception of the
manner in which this is completed a general
knowledge of the disposition of the muscular
fibres of the organs is necessary. At full time
the uterus is to be considered as consisting of
three distinct portions, viz. the body, lower
uterine segment, and cervix (see Fig. 1).
They are in a general manner to be differen-
tiated from each other by their relationship to
the peritoneal investment ; on the body the
peritoneum is closely adherent, on the lower
uterine segment it is loosely attached, while
the cervix has practically no peritoneal covering
whatever. Of these three portions the body alone actually contracts, and
is to be considered a power, the lower uterine segment and cervix are
purely passive, and are in truth passages. The muscular fibres of the body

Fio. 1. — Diagram of full time gravid
uterus showing main disposition
of fibres. A, Body proper ; B,
lower uterine segment (longi-
tudinal) ; C, cervix circular.

LABOUE, PHYSIOLOGY OF

133

are irregular in their distribution. Those of the lower uterine segment are
mainly disposed in a longitudinal direction, while in the cervix the disposi-
tion of the pelvis is mainly circular.

With the onset of labour retraction of the body of the uterus com-
mences. This is at first associated with the painless uterine contractions
which are ever present during pregnancy. As the result of retraction the
cavity of the body proper is permanently decreased in size, and the
muscular wall at the same time becomes thicker. The retraction of the
body pulls upon and lengthens the lower uterine segment, and through it
upon the cervix. The cervix is thus pulled upon in an upward direction,
and its passive circular fibres (commencing at the os internum) gradually
yield from above downwards, with the result that the canal of the cervix is
dilated, and now forms part of the general uterine cavity which thus

Pig. 2. — Pull time gravid uterus.
Primiparse, showing cervix
closed. The dotted line demon-
strates foetal ovoid.

Fig. 3. — Commencing dilatation of
cervix before actual onset of labour
pains ; stage of " lightening " before
labour.

Fig. 4. — Commencement of first
stage with early dilatation of
os externum.

compensates for the diminution in the body proper (Figs. 2, 3, 4).
During this period the patient is usually unaware of any active changes
occurring, although she experiences a sensation of the uterine tumour having
fallen somewhat ; this is generally associated with a feeling of more easy
respiration, which has been called the " lightening " before labour. Vaginal
examination at this stage will show the cervix to be shortened, but the os
externum usually closed in primiparee.

In due course uterine contractions become stronger and are associated
with painful sensations, the patient now passes into the active first stage
of labour. During this stage a similar though increased action of the
uterus continues, the body proper contracts and retracts with a correspond-
ing increase in the traction on the lower uterine segment, which results in a
slight lengthening of this portion of the uterus and a gradual dilatation
of the os. Should there be difficulty in the dilatation of the cervix
through rigidity or other causes, an increased strain is thrown on the
lower uterine segment, which causes it to become more and more lengthened
and correspondingly thinned (see Eupture of Uterus, p. 295). In consequence
of the continued retraction of the body proper with the associated increased
thickness of its walls, and at the same time the thinning of the lower
uterine segment, there is formed a sharp line of demarcation between these
two portions of the uterus throughout its circumference ; this is known

134

LABOUB, PHYSIOLOGY OF

as the " retraction ring " (Fig. 5). As is to be expected, the greater
the retraction and corresponding thinning of the lower uterine segment,
the more marked does this ring become ; its detection, therefore, may be
of much practical value as evidence of impending rupture. With the com-
pletion of the first stage and full dilatation
of the os there is an entire absence of any
constriction formed by the cervix. The uterus
and vagina now form one smooth, continuous
canal — "complete canalisation." During this
stage but slight descent of the ovum occurs, the
main effect having been the stripping of the
cervix and lower uterine segment off the lower
pole.

Full canalisation having been completed, ex-
pulsion and descent of the ovum now take
place, and the second stage of labour com-
mences.

The uterine force is now assisted by con-
tractions of the abdominal and thoracic
fig. 5.-Gravid uterus towards end of muscles, and by their combined efforts the
first stage, showing a tody proper child is expelled. The combined force has

retracted ; B, lower uterine segment . . r. . . _ ^ w

lengthened ; and r, retraction ring, been variously estimated at from 17 to 57
lbs. to the square inch. The direction of the
applied forces is downwards and backwards in the axis of the brim of the
pelvis.

Third Stage. — For the completion of this stage both the primary and
secondary powers are called into action, though not in combination. By
contraction and retraction of the uterus the placenta and membranes are
separated and expelled from its cavity, their further expulsion and birth
to be completed by the unaided action of the secondary powers.

In the first stage there is exercised on the ovum by the contractions of
the body of the uterus a general pressure, which is transmitted at right angles
to its surface. The entire superficial area of the ovum is therefore acted
upon, except the lower pole, which is in contact with the passive lower
uterine segment. Pressure is by this means conducted through the ovum
upon the lower uterine segment, which yields and lengthens ; at the same
time the uterus retracts, and by dragging on the cervix opens up its canal ;
into this the ovum bulges, and transmits pressure laterally on its walls,
and thus assists in the further dilatation. Also, from the pulling-up of the
cervix through retraction the cervix is further dilated, and the lower pole
of the ovum separated from the uterine wall. As a result the lower pole
of the ovum is exposed and presents. This normally consists of the
membranes and a quantity of contained liquor amnii, the so-called bag of
forewaters. After full dilatation of the cervix the bag of forewaters usually
ruptures. From the close adaptation of the soft parts of the pelvic canal
around the presenting part (girdle of contact), the liquor amnii which sur-
rounds the foetus in the uterine cavity is prevented from escaping en masse
along with the forewaters. During the subsequent stages of labour it
escapes gradually. Its retention is of much value in preventing a complete
moulding of the uterine wall to the body of the foetus, which would thus
seriously compress the placenta and obstruct the circulation within it.

Full dilatation of the cervix and rupture of the membranes, with escape
of forewaters, terminates the first stage, and descent of the foetus now
commences.

LABOUR, PHYSIOLOGY OF

135

The duration of the first stage varies greatly. As can only be expected,
it is normally much longer in primiparse from want of previous dilatation.
Calculating from the time when pains occur at fairly regular intervals of
from five to seven minutes, the average first stage may be described as
occupying eight to ten hours in a primipara, and Hve to seven hours in a
multipara.

Descent of the foetus now commences and opposition is offered by the bony
pelvis and pelvic floor. The former is overcome by a process of accommo-
dation of the presenting part to the irregular passages, in the course of which
a complicated though definite mechanism is undergone and described (see p.
159). This mechanism of accommodation is entirely due to the combined
efforts of the powers and resilient pelvic floor. The presenting part is im-
pelled downwards during the pains, and through the resiliency of the pelvic
floor recoils after each contraction ceases. By this means a constant up-and-
down movement is maintained, which favours and secures the transit of the
presenting part through the most available channel. At the same time, by
means of the pliability of the presenting part it becomes moulded, and thus
adapted to the varying available space. The passage of the child through the
compact pelvic floor is rendered possible by the mobility of its pubic and sacral
segments. The former is drawn
upwards by the retraction of the
uterus, while the latter is forced
downwards by the pressure of the
advancing part, as if by a folding-
door mechanism, the floor is thus
opened up and the expulsion of
the child facilitated.

The descent of the foetus is
almost entirely confined to the
presenting head; the breech or
upper pole of the foetal ovoid
may be found to be exactly at
the same level when the head
appears at the vulva as at the
commencement of labour. This
is explained by the pliability of
the foetal ovoid, which, from the
pressure exercised upon it from
all sides except at its lower pole,
is elongated by the straight-
ening of its vertebral column
(Figs. 6, 7, 8). After the
birth of the head a short inter-
val of rest occurs, after which
contractions recur, and the body
is expelled. The duration of
the normal second stage may
be said to average three hours
in a primipara, and two hours in a woman who has previously borne
children.

During and after the expulsion of the foetus the tonic retraction of the
uterus causes it to firmly compress the decreasing uterine contents.
Thus, after the birth of the child the uterus closely surrounds the secundines
(placenta and membranes). Intermittent uterine contractions continue, and

Fig. 6.

-Commencing labour, showing complete attitude
of foetal flexion.

136

LABOUR PHYSIOLOGY OF

cause their separation by diminishing the area of attachment, and after
separation expel them into the vagina, from which they are forced by the
unaided action of the secondary powers, and born. The tonic retraction of
the uterus permanently maintains the closure of the uterine sinuses at the
site of the separated placenta, and thus prevents excessive haemorrhage,
while recurring intermittent contractions expel from the uterus any blood
which may ooze.

Separation of the placenta does not commence till after the birth of the
child, and is attained by a process of what is known as detrusion. This
consists in the extensive diminution of the placental site by contraction
and retraction of the uterine wall to such a small area (4 by 4| inches) that

Fig. 7.— Labour, second stage, showing commencing
straightening of foetus.

Fig. 8.— Birth of head, showing extension of foetal
ovoid. A, thinning of pelvic floor projection.

the placenta, though semi-elastic in consistence, is torn from its attachment.
Detachment, as observed from a series of frozen sections of the third stage
of labour,- would appear to occur gradually from below upwards, and thus
when completely separated the organ is expelled, doubled up in an
elongated form, the entire process of separation and expulsion from the
uterus being due to the same cause. Separation of the membranes from
the body proper also occurs only during the third stage. They are partially
detached in a similar manner to the placenta by diminution of their area
of attachment through contraction or retraction of the uterus; by this
means they are thrown into a series of wavy ridges. Their complete
separation is only attained by the traction of the placenta during its
expulsion.

The amnion and chorion are of different elasticity, and thus form ridges
independently of one another, the intervening layer being stretched and

LABOUR, PHYSIOLOGY OF

137

lacerated. If strong adhesions exist, therefore, between the chorion and the
uterine wall, it is no uncommon thing to have the amnion expelled entire
with the placenta, leaving the entire chorion in utero, a condition very apt
to be overlooked when examining the secundines to ascertain their com-
plete expulsion. The average duration of the third stage is about twenty
minutes.

After labour retraction and contraction are so complete that no space
exists in the uterine cavity ; the uterine walls, which are 1\ to 1| inches
thick, are firmly apposed to one another. Occasionally a blood -clot,
continuous with the thrombi in the vessels at the placental site, may be
present. The post-partum uterine cavity from the external os to the
fundus measures about 7.1, inches.

Hard Passages

The passages, for convenience of description, may be divided into hard
and soft — the former are represented by the bony pelvis, and the latter
by the lower uterine segment, cervix, and vagina.

The bony pelvis, which forms the boundaries of the hard canal through
which the uterine contents pass during labour, is restricted to what is
known anatomically as the true pelvis. This, from its irregular shape, is
difficult to describe so as to give a clear conception of its nature. For this
purpose three planes may be drawn at different levels, the dimensions of
which will serve to show the
varying nature of the contour
of the canal : (Fig. 9) the first,
at the upper level, which is
known as the brim, inlet, or
superior strait ; the second, at the
level of a line drawn from the
middle of the symphysis pubis
to the junction of the second
and third sacral vertebrae, is
known as the cavity ; and the
third, known as the outlet or
inferior strait, from the lower
border of the symphysis pubis to
the tip of the coccyx. So as to
estimate the irregular nature of
the canal the dimensions of each
plane are determined by measuring
the antero-posterior, the trans-
verse, and oblique diameters.

The antero-posterior or con-
jugate diameter at the brim ex-
tends from the Upper border of FlG- 9-— Vertical mesial section of bony pelvis, showing
,i i . i . . ,-, planes at which measurements are taken (1, 2, 3), and

the Symphysis pubis tO the angles of plane of brim 60° and outlet 11°.

sacral promontory, and measures

4 inches; at the second plane (cavity) it measures 44 inches; and at
the outlet, with the tip of the coccyx firmly pushed back, it is 5 inches
in length.

The transverse diameter of the brim is measured at the widest distance
between the iliac bones, and measures 5 inches. In the cavity it is 4|
inches, and at the outlet, from one ischial tuber to the other, its dimension

jugate.

Oblique.

Transverse.

138 LABOUR, PHYSIOLOGY OF

is 4 inches. The two oblique diameters of the brim are taken from the sacro-
iliac joint on one side to the ilio-pectineal eminence on the opposite side,
and are called right and left respectively, according to the joint from which
they are taken. They measure 4| inches. In the cavity and at the outlet
they are measured parallel to those at the brim, and are of the same length,
viz. 4h inches.

In considering the diameters of the pelvis as a whole (see table), it will
be noted that the conjugate from above downwards is increased by an inch,
the transverse is decreased by an inch, while the obliques remain the same
throughout.

Table

Brim

Cavity ....
Outlet ....

Another internal diameter which is of much practical value remains to
be described, viz. the diagonal conjugate. It is measured from the lower
border of the symphysis pubis to the sacral promontory, and is 4f inches. It
is of importance as being a measurement which can be readily taken by the
examining finger, and from which by the subtraction of three-quarters of an
inch the length of the conjugate of the brim (conjugata vera) can be
estimated.

In a general description of the normal pelvis the brim is considered as
heart-shaped. The cavity, as the diameters show, is circular, while the outlet
is diamond-shaped.

In the erect posture the plane of the pelvic brim forms an angle of 60°
with the horizon, the sacral promontory is about 3J inches higher than the
upper border of the symphysis pubis. Without the soft parts the plane of
the outlet forms an angle of 11° with the horizon; the tip of the coccyx
being about half an inch higher than the lower border of the symphysis
pubis. With the soft parts in situ the plane of the outlet is very materially
changed.

In the measurement of the pelvis there are three external diameters
which are of practical importance. The external conjugate from the spine
of the last lumbar vertebra to the upper border of the symphysis. It is Cl-
inches, and is of value in estimating the true conjugate. The interspinous
diameter from one anterior superior iliac spine to the other, 9 J inches, and
the intercristal, between the widest portion of the iliac crests, 10|- inches, are
of more value as regards their comparison with each other than in the
estimation of their actual length. Under normal conditions the inter-
spinous should be at least an inch less than the the intercristal ; any
approximation between them is indicative of flattening of the iliac bones, a
condition usually met with in rachitic pelvic deformity (see p. 221).

The soft structures within the pelvis modify to a greater or less extent
its various diameters ; this is most evident at the outlet, which is filled by the
pelvic floor. The pelvic floor may be described as a thick, compact musculo-
membranous diaphragm traversed by three slit-like canals — the vagina,
rectum, and urethra. The former, which mainly is concerned in parturition,
traverses the floor in the erect female at an angle of 60° to the horizon, or
in other words parallel with the plane of the pelvic brim. On its external
or skin aspect the pelvic floor bulges in a convex manner beyond the plane
of the bony outlet to the extent of nearly 3 centimetres ; this is described as
the pelvic floor " projection " (Fig. 8).

LABOUK, PHYSIOLOGY OF 139

For descriptive purposes the floor may be considered as composed of two
segments divided from one another by the transverse vaginal slit, and
known respectively as the anterior or pubic segment and the posterior or
sacral segment. The former consists of the anterior vaginal wall, bladder,
urethra, and retropubic fat, is loosely attached to the bony canal, and is
freely movable. The latter consists of the posterior vaginal wall and
structures posterior to it, is firmly attached and less mobile, — features of the
greatest value in considering the method by which this seemingly im-
penetrable barrier to the passage of the child is overcome during labour.

Viewed as a whole the parturient passage may be considered as a bony
canal merely lined by soft structures in its upper half, but from the thick-
ness and consistency of these soft structures in its lower half materially
modified by them as regards direction. As has already been stated, the
plane of the pelvic brim and direction of the vagina respectively form an
angle of 60° with the horizon, and are thus parallel. The axis of the brim
and direction of the vaginal canal which forms the exit through the outlet
must, therefore, be at right angles. Before expulsion of the uterine con-
tents can be accomplished, therefore, a curved path must be traversed
equivalent to half a circle. This curvature of the pelvic canal is described
as the " curve of Cams," or axis of the pelvic canal. For clinical purposes
the axis of the inlet may be roughly considered as the direction of a line
drawn from the umbilicus to the tip of the coccyx.

Third Factor. — The Passengers. — These are represented by the foetus,
placenta, and membranes, and liquor amnii.

The Passenger or Ovum. — For descriptive purposes the ovum may be
divided during labour into three parts: (1) The free or presenting part, which
can be felt by the examining finger ; (2) The obstructed part, which is in
contact with the girdle of resistance, that is to say, the portion which is in
contact with the genital canal. In the first stage the girdle of contact is
formed by the cervix, and in the second stage by the vagina which lines the
bony pelvis. (3) The part which is directly acted upon by the powers, and
lies above the girdle of resistance. As a whole the ovum when entire is of
an ovoid shape, and under normal circumstances the lower end of the ovoid
is the smaller ; by this means it is accommodated to the normal ovoid con-
tour of the uterine cavity. After rupture of the membranes the foetus alone
is to be considered ; this also, from the marked flexion of its parts upon one
another, is of an ovoid shape, the smaller end of the ovoid being the cephalic
extremity. This accounts for the frequency of cephalic presentations, 96 per
cent; the foetal ovoid conforming with the shape of the uterine cavity
(Fig. 2). Though forming the smaller end of the foetal ovoid, the foetal
head in itself forms the largest and least compressible portion of the uterine
contents, and, as has already been stated, is the portion of the foetus which
offers the greatest difficulty to expulsion. This is not merely from the size
of its diameters, but also from the fact that it is less compressible. Its
incompressibility, however, is not absolute, the bones are incompletely
ossified, and offer between them membranous interspaces, so called sutures,
which allow of a considerable amount of overriding or moulding as it is called.

The bones of the cranial vault — occipital, frontal, and parietal — are
separated from one another by one longitudinal and two transverse sutures,
respectively named sagittal, lambdoidal, and coronal. Where the sutures
cross each other, membranous interspaces of considerable dimensions are
present, and are called fontanelles ; thus where the sagittal and lambdoidal
sutures meet is the posterior fontanelle, and where the sagittal intersects
the coronal the anterior fontanelle or bregma (Fig. 10).

140

LABOUK, PHYSIOLOGY OF

ii.

The posterior fontanelle is triangular in shape, and has three sutures
running from it. The anterior fontanelle is larger than the posterior,
lozenge - shaped, and has four sutures entering into its formation. The

space between the anterior and posterior
fontanelles, and bounded laterally by the
parietal eminences, is known as the vertex.
The regions of the head are the occiput,
vertex, brow or sinciput, and face.

Diameters. — For practical purposes a
series of measurements of the foetal head,
known as diameters, are taken ; these may
be tabulated as longitudinal, transverse, and
vertical.

A. Longitudinal. — Occipito-mental, from
the chin to the occipital protuberance,
5 inches. Occipitofrontal, from the glabella
or root of the nose to the occipital protuber-
ance, 4i inches. Suboccipito - bregmatic,
from the anterior angle of the anterior
fontanelle to the junction of the occiput with
the neck, 4 inches. This diameter may be
shortened almost half an inch by taking
the measurement from the posterior angle
of the bregma, a point of importance in
the movement of flexion in the mechanism

Fig. 10.— Diagram of foetal head, showing 0f labour, which See (p. 159).

sutures. B, Anterior fontanelles: I. _ rn i^. . ' . ...

longitudinal and vertical sutures ; II. JB. IranSVerSB. Bipanetal, joining the

transverse sutures. parietal eminences, 3| inches. Bitemporal,

between the widest points of the coronal suture, 3 inches. Bifrontal,
the widest part of the head anteriorly, 2| inches.

C. Vertical. — Fronto-mental, from the chin to the upper part of forehead,
3 inches. Trachelo-bregmatic, from the foramen magnum to the bregma,
3 inches.

The circumference of the head in the occipito-mental plane is 16 inches,
in the occipito-frontal plane 14 inches, and in the suboccipito-bregmatic
plane from 11 to 12 inches.

As a whole the foetal head is wedge-shaped ; viewed from above it slopes
away forwards from the parietal eminences and back to the occiput.

During labour the diameters of the head are considerably diminished
by the overriding of the bones, equitation. The occiput passes beneath
the parietals, and the posterior parietal bone is driven beneath the
anterior.

From the measurements of the foetal head it will be seen how closely
they correspond with the available capacity of the bony parturient canal,
and how finely balanced, therefore, must be the mechanism to allow of
expulsion through its lumen.

As has already been shown (see " Foetus," vol. iii), the foetus lies in a mem-
branous sac, surrounded by liquor amnii, and attached to the uterus by the
placenta and umbilical cord, through which it derives its nourishment and
oxygen, and excretes waste products.

As the foetus forms by far the largest portion of the ovum its expulsion
is undoubtedly the main feature in the mechanism of labour. It has,
therefore, to be closely studied : 1st, as regards the manner it is disposed
in the uterine cavity at the onset of labour ; and, 2nd, with reference

LABOUR, PHYSIOLOGY OF 141

to the measurements of the largest diameters which pass through the
parturient canal during labour, the foetal head.

"Disposition" of Foetus in Titer o. — By this is meant the general
relation of the foetus as a whole to the uterine cavity. This embraces (a)
the relation of the foetal parts to one another, " attitude " of the foetus ; (&)
the relation of the long axis of the foetus to the uterine cavity, with special
reference to the most dependent part or " presentation " of the foetus ; and
(c) the relation of the presenting part to the parturient canal, " position " of
foetus. The " attitude " of the foetus is one of almost complete flexion.
The head is flexed on the chest so that the chin is in contact with the
sternum. The vertebral column is bent on its ventral aspect, and the
thighs, knees, and elbows are all acutely flexed. By this means the foetus
forms an ovoid, and occupies the least possible space, and at the same time
is a compact mass which is acted upon by the powers during expulsion to
the greatest advantage. Such a marked degree of flexion is obtained that
the length of the foetal ovoid in utero is barely half of the actual length
of the child when born. Thus a full time child, of 20 inches measures in
utero scarcely 10 inches from pole to pole. The cephalic extremity or pole
is the smaller (Fig. 2).

In its disposition in utero the long axis of the foetal ovoid naturally
corresponds to the long axis of the uterine cavity, which is usually vertical.
Thus one or other pole of the foetus usually presents. In over 96 per cent of
cases the cephalic pole presents ; this is due to the accommodation of the foetal
ovoid to the uterine ovoid, the smaller end of the ovoid uterine cavity
being normally the lower (Fig. 2). In 3 per cent of full time labours
the podalic extremity or breech of the foetus presents ; in these instances the
change of presentation is probably due to some change either in the foetal
ovoid or in the shape of the uterine cavity. In less than *5 per cent the
foetus lies transversely in the uterus (shoulder presentations).

The relation of the presenting part to the parturient canal, so-called
"position," varies considerably before the onset of labour. In vertex
presentations the different positions are named according to the situation of
the occiput. Under normal conditions the longest diameter of the vertex
(occipito-frontal) lies in one or other oblique diameter of the brim. Thus
the occiput may be to the front or back, either on the left or right side.
Four positions are thus described, viz. left occipito-anterior, right occipito-
anterior, right occipito-posterior, and left occipito-posterior — the first,
second, third, and fourth positions of Naegele in the order named. The
relative frequency of these positions is L.O.A. 65 per cent, E.O.A. 10 per
cent, R.O.P. 20 per cent, L.O.P. 5 per cent. It will then be seen that in
85 per cent of vertex cases the occipito-frontal diameter lies in the right
oblique diameter of the pelvis, and 65 per cent with the occiput forwards.
This is accounted for by the fact that the right oblique is- the most available
diameter of the pelvic brim, the left oblique being encroached on by the
full sigmoid flexure of the colon. That the occiput is so frequently forwards
is to be explained by the accommodation of the foetal ovoid to the uterine
ovoid, the convex back of the foetus becoming accommodated to the
markedly concave anterior aspect of the uterine cavity. From its frequency,
therefore, the normal presentation and position is the vertex L.O.A.

Further reference to the position, presentation, and attitude of the foetus
will be found on p. 151 et seq.

142 LABOUK, STAGES AND DUKATION

Stages and Duration of Labour

Definitions . . . .142
Premonitory Stage . . .142
First Stage . . . .143

Second Stage . . . .146
Third Stage . . . .148

The process of labour is divided into three stages : — The first stage, or
stage of dilatation ; the second stage, or stage of expulsion ; and the third
stage, or "placental stage. Further, for clinical purposes it is convenient to
include an additional stage — the premonitory stage, inasmuch as labour is
ushered in by a train of symptoms and physical signs of sufficient definite-
ness to warrant such an addition.

The Premonitory Stage. — Duration. — The premonitory stage of
labour is most irregular, both in the time of its onset and the degree of its
symptoms. As a rule the symptoms first show themselves one or two days
before labour — properly so-called — starts. In priniiparas the symptoms are
well marked ; in multiparas they may be slight or even entirely absent.

Phenomena. — The principal phenomena associated with this stage are
as follows : —

(1) The Occurrence of False Pains. — The commonest phenomena of
commencing labour consists in the occurrence of irregular pains, distributed
over the abdomen generally. These pains, which may be considered as
amplifications of the painless contractions of the pregnant uterus, are known
as " false pains " or dolores presagientes. They occur at widely separated
intervals, and are distinguished from true labour pains by their irregularity,
and by the fact that they are felt over the abdomen generally and not in
the back.

(2) The Descent of the Foetal Head into the Pelvic Cavity. — This
sign is of value in multiparas, as in their case the head does not as a rule
descend until about the commencement of the first stage. In primiparas,
on the other hand, it is valueless, as in them the foetal head can as a rule
be found in the pelvic cavity during the last three weeks of pregnancy. It
must also be borne in mind that descent of the head may be prevented by
disproportion between its size and the size of the pelvic brim or cavity, or
owing to some intra-uterine obstruction to the descent. The commonest
causes of disproportion are contracted pelvis, mal-presentations of the head,
hydramnios, and tumours growing from or occupying the pelvis. The
commonest causes of intra-uterine obstruction are low situation of the
placenta, hydramnios, twins, and myomata obstructing the cervical canal or
lower uterine segment.

(3) Partial Dilatation of the Cervical Canal. — The changes which occur
in the cervix during this stage differ in the case of priniiparas and of multi-
parse. In primiparas, the internal os usually commences to dilate at the
beginning of labour, while the external os may remain closed for some time
after labour has started. In multiparas, on the other hand, the external os
is as a rule dilated for some days before labour starts ; and, in some cases,
the internal os may share in this dilatation, though, as a rule, its dilatation
commences during this period. In both priniiparas and multiparas, the
operculum or plug of mucus which fills the cervical canal is expelled.

(4) Swelling of the Yulva. — A slight degree of swelling of the vulva
very constantly occurs. It is due to the increased obstruction offered to
the return of blood, owing to the pressure exerted upon the veins by the
descending head.

(5) The Occurrence of a Blood-Stained Discharge. — The discharge or

LABOUR, STAGES AND DURATION 143

show — as it is generally termed — which occurs at this period consists of
viscid mucus from the cervix, and a small quantity of blood. It is prob-
ably closely connected in its quantity and onset with the commencement
of dilatation of the cervix.

The falling of the fundus of the uterus is sometimes given as one of
the phenomena of this stage. At the end of the thirty-sixth week the
fundus reaches to the ensiform cartilage, while at the commencement of
labour it is found to be midway between the ensiform cartilage and the
umbilicus. As, however, this change gradually occurs during the last three
or four weeks of pregnancy, it can hardly be considered as one of the
symptoms of this stage.

Diagnosis. — It is by no means easy in all cases to determine whether
the patient has reached the premonitory stage of labour or not. It is a
question which frequently can only be settled by carefully looking for the
various symptoms and physical signs which have been described. The
fixity of the head is a tolerably reliable guide in multipara?, if it is present.
On the other hand, it is of no value in prirniparse. If the head is not fixed,
and other signs point to the likelihood of the patient being in labour, an
attempt must be made to ascertain if there is any cause sufficient to pre-
vent such fixation. The occurrence of irregular pains is sometimes decep-
tive, as they may be due to flatulence, etc. A considerable degree of
dilatation of the cervical canal is a tolerably certain sign. Slight dilata-
tion, on the other hand, is but of a negative value.

First Stage. — Duration. The first stage, or stage of dilatation, com-
mences with the onset of true uterine contractions, and ends with the full
dilatation of the os and the rupture of the membranes. Its average dura-
tion is in prirniparse from eleven to twelve hours, in multiparas from six to
eight hours.

Phenomena. — The chief phenomena of the first stage are : — the uterine
contractions, the taking up and dilatation of the cervix, and the rupture of
the membranes.

The contractions of the uterine muscle fibres, or the " labour pains " as
they are generally termed, are involuntary, occur intermittently, cause a
varying degree of pain, and sweep over the organ as a peristaltic wave.
The effect of a contraction upon the shape of the uterus is to cause a
diminution of the transverse diameters, and an increase in the longitudinal
diameters and in the thickness of the walls ; the effect upon the cavity of
the uterus is to cause a diminution in the size of the latter. The result of
this diminution is to cause increased pressure upon the ovum, and, as the
latter is incompressible, to force it in the direction of least resistance.
Various factors combine in making the region of the internal os the area of
least resistance to the advance of the ovum, and consequently the lower
pole of the ovum tends to advance in this direction. The duration of a
contraction is from three to ten seconds, and the interval between two con-
tractions may at the commencement of labour be an hour or more, while, as-
the second stage approaches, they may occur every ten to twenty minutes.

While the uterine contractions are at work intermittently diminishing
the size of the uterine cavity, there is another change taking place in the
fibres which results in the permanent diminution of the cavity. This is
the occurrence of retraction, and, as it is a most important process, it is
well to devote a few lines to a description of it. The uterus consists of two
distinct regions or segments — the upper uterine segment and the lower
uterine segment. The upper segment — whose main function is to expel
the fcetus — contains the contractile fibres of the uterus ; the lower segment

144 LABOUB, STAGES AND DUEATION

— whose main function is to expand in order to allow the passage of the
foetus — contains but a very small proportion of contractile fibres, and so may
be regarded as the non-contractile segment of the uterus. The junction
between the two is known as the contraction ring, or sometimes as the ring
of Bandl. The latter term, however, implies the acceptance of Bandl's
theory as to its origin, and unless we are prepared to accept this, it is better
to use a term which does not tie us to a fixed theory. At the commence-
ment of labour the contraction ring is situated slightly above the internal
os, and during the whole labour it is rising progressively higher on the
uterus, so that — in an extreme case where some obstruction to delivery
existed, and labour was consequently much prolonged — the contraction ring
might be found at the region of the umbilicus. The gradual rising of the
ring upwards is associated with an equally gradual thickening and shorten-
ing of the upper or contractile segment, and a similar thinning and
lengthening of the lower segment. This change is the effect of retraction,
and retraction itself may be described as a process by which the muscle
fibres do not return to their full length after each contraction, but remain
slightly shortened. There is probably also an actual change of position of
the fibres, at least in their relationship to one another, so that those which
at the commencement of labour were lying end to end after some little
time ' lie with their ends overlapping, and after a longer time may even lie
side by side. The retraction of the fibres always occurs towards the fundus,
or, in other words, the contraction ring always tends to move upwards to-
wards the fundus. The ring can be felt through the abdominal wall, as a
depression running obliquely across the uterus, in those cases in which
labour has been very strong or unduly prolonged. In normal labours it
can rarely be felt, as it does not rise sufficiently high above the symphysis
pubis. It is most essential jto be able to recognise the presence of the con-
traction ring, as it furnishes an absolute indication of the effect of the
uterine contraction upon the uterine wall.

The taking up and the dilatation of the cervix are the essential pheno-
mena of this stage, as is shown by the name usually given to it — the stage
of dilatation. The taking up of the cervix is the term applied to the
process by which the cervical canal is made continuous with, and so part
of, the lower uterine segment. The extent to which this process occurs
differs in primiparas and in multiparas, as will be seen by reference to the
diagrams.

In primiparas, at the commencement of labour the cervix is long, and
presents more or less its original outline, having both the external and the
internal os closed. The first step consists in the dilatation of the internal
os, then of the supra-vaginal portion of the cervical canal, and then of the
infra- vaginal portion. As soon as this last has occurred the taking up of
the cervix is complete, and the uterine and cervical cavities are continuous.
The os externum, which now forms the uterine orifice, is still undilated.

In multiparas, on the other hand, at the commencement of labour the
external os is as a rule sufficiently dilated to admit one or two fingers, and
the cervical canal is somewhat everted as the result of former lacerations,
etc. Consequently, when we examine vaginally the finger passes through
the external os, and first is obstructed by the internal os. As soon as labour
commences the internal os dilates, and also the supra- vaginal portion of the
cervical canal. This as a rule completes the degree of taking up of the cervix
which occurs, and the remainder of the cervix, i.e. the lower portion and
the already somewhat dilated os externum, retracts synchronously when the
time comes for the uterine orifice to dilate. The result of this difference

LABOUR, STAGES AND DURATION

145

between primiparee and multiparas, is that in the former when the taking
up of the cervix is complete, the uterine orifice is encircled by extremely
thin, paper-like edges, formed by the borders of the original os externum

Fig. 11. — Diagrammatic representation of the manner in which the cervix is taken up in the case of a primipara.
OB, os externum ; 01, os internum ; CR, contraction ring. (Schroeder.)

alone. In multiparas, on the other hand, the uterine orifice is surrounded
by blunt, comparatively thick edges, formed by the portion of the cervical

Fig. 12. — Diagrammatic representation of the manner in which the cervix is taken up in the case of a multipara.
OB, os externum ; 01, os internum ; CR, contraction ring. (Schroeder.)

wall which has not been taken up, as well as by the margin of the os
externum.

As soon as the taking up of the cervix is complete the next step is the
dilatation of the uterine orifice. This is brought about by the downward
vol. vi 10

146 LABOUE, STAGES AND DUKATION

pressure of the advancing ovum and by the gradual retraction upwards of
the remainder of the cervix. As soon as this retraction is so complete that
all traces of cervical projection have disappeared, and the vaginal and
uterine cavities have become practically continuous, the cervix is said to be
fully dilated.

The final phenomenon of the first stage is the rupture of the membranes.
This event, which is due to the loss of support experienced by the mem-
branes owing to the retraction of the cervical walls, usually synchronises
with the full dilatation of the os. In certain cases, however, owing to a
failure of adaptation between the presenting part and the lower uterine
segment, the membranes at an early period in the first stage have to with-
stand the full force of the uterine contractions, transmitted to them through
the liquor amnii, and consequently rupture almost at once. In such cases
all the liquor amnii escapes with a rush, an occurrence which never happens
under normal circumstances, when there is due adaptation between the
presenting parts and the lower uterine segment. In these cases, only the
liquor amnii in front of the head escapes, as the remainder is dammed up by
the presenting part.

Constitutional Symptoms. — The constitutional symptoms of the first
stage are very slight. At the commencement the patient in many cases
pursues her ordinary occupations, save when a pain occurs. As the stage
advances, the pains become more frequent and of longer duration. The
pulse and temperature are as a rule unaffected, save for a slight increase in
frequency in the rate of the former during a pain. Gastric disturbance
associated with vomiting is of common occurrence, especially towards the
end of the stage.

Diagnosis. — As a rule it is easy to determine the onset of the first
stage. All the symptoms which have been given under the premonitory
stage are present, but are more marked. The painless contractions of the
uterus disappear and are replaced by painful contractions. The latter can
be recognised by laying the hand flat upon the abdomen of the patient, and
determining the fact that the onset of a pain is associated with an easily
perceptible hardening of the uterine muscle. The character of the pains
serves to distinguish between the first and the second stage, even without
going into the determination of the condition of the cervix and of the
membranes. In the first stage the pains are constituted solely by involun-
tary contractions of the uterine muscle fibres. In the second stage, as will
be seen, the patient accompanies each uterine contraction by voluntary
contractions of the abdominal muscles — bearing down, as it is termed.
(For "Management," see p. 188.)

Second Stage. — Duration. — The second stage, or stage of expulsion,
commences with the full dilatation of the os and the rupture of the
membranes, and ends with the expulsion of the child. Its average duration
is from one to two hours in primipara?, and from ten to fifteen minutes in
multiparas.

Phenomena. — The chief phenomena of the second stage are the
continuance of involuntary contraction and retraction of the uterus, the
addition of voluntary contraction of the abdominal muscles, and the conse-
quent expulsion of the fcetus.

The nature of the uterine contractions remains unchanged, save that they
become more violent, and last for a longer time. The interval between
them is also lessened. They vary in length from thirty to sixty seconds,
and occur every five to seven minutes up to the actual time of expulsion,
when they are almost continuous. Eetraction of the muscle fibres also

LABOUR, STAGES AND DURATION 147

continues ; and its importance is now seen, as it enables the uterus to reduce
the size of its cavity to suit its lessening contents. The voluntary contrac-
tions of the abdominal muscles impart to the second stage pains their
expulsive character. As each contraction commences, the patient fixes her
diaphragm by closing the glottis after a deep inspiration, and, contracting
her abdominal muscles to the utmost, brings all the force she can to bear upon
the uterus and its contents. The reason that these voluntary expulsive
efforts do not occur during the first stage is obvious. At that time, the
undilated cervical canal offers a bar to the advance of the uterine contents,
and hence the effect of the contraction of the abdominal muscles is merely
to drive the entire uterus downwards into the pelvis without in any way
farthering the expulsion of the ovum. In the second stage, this obstruction
is removed, and the compression of the uterus by the contractions of the
abdominal muscles materially assists in hastening the delivery of the foetus.

The expulsion of the foetus commences as soon as the membranes
rupture. The presenting part is driven downwards through the vagina
until it reaches the perinseuni, where there is usually some little delay
Then as each fresh contraction occurs, the presenting part advances a little,
and can be seen at the vulva separating the labia ; and as the contraction
passes off, it again recedes into the vagina. Finally, it descends so far that
it does not recede, and then the next contraction will in all probability
cause its expulsion. As the presenting part is passing over the perinseum,
the pain caused is so severe that the patient is compelled to cry out. This
act, by opening the glottis, checks all efforts at bearing down, and so slows
expulsion. In this way a longer time is given to the perinseum to dilate,
and the tendency to laceration is diminished.

The necessary dilatation of the vagina, vulva, and perinseum is permitted
by the softening these tissues undergo as the result of serous infiltration
of the connective tissue. This is due, first, to the active hypersemia of the
vessels which occurs during labour, and, secondly, to the fact that the return
flow of blood being obstructed by the pressure exerted upon the veins by
the presenting part there is a consequent increase of intra-vascular tension.

Constitutional Symptoms. — The constitutional symptoms of the second
stage are more marked than are those of the first, owing to the fact that the
uterine contractions are stronger, and that the descent of the foetus through
the vagina increases the patient's suffering. The frequency of the pulse-rate
and of respiration is increased during the pains, and profuse sweating may
occur. As the foetus presses more and more upon the rectum, the patient
experiences a strong desire to go to stool, although there is usually
nothing in the bowel to evacuate.

Diagnosis. — The diagnosis of the onset of the second stage can, as has
been mentioned, be made by the change in the character of the pains.
Further, the patient herself, or her attendants, can usually inform us
whether the membranes have ruptured or not, so obviating the necessity of
making a vaginal examination. If the latter is made, the fact that the
cervical canal is fully dilated can be determined.

The progress which the foetus is making through the vagina can be
determined by abdominal palpation or by vaginal examination. By the
assistance of the former we can follow the progressive descent of the
presenting part by noting the rate at which it travels downwards behind
the symphysis. In the early part of the second stage, the height above the
symphysis of some portion of the presenting part — for instance, the chin in
vertex presentations — can be measured in finger-breadths. As labour
advances, the portion which we have taken for our guide will be found to

148 LABOUK, STAGES AND DUKATION

approach the level of the symphysis, and then to sink below the latter.
The rate of advance can then be followed by sinking the finger-tips into the
true pelvis ; while by the time we can no longer reach the chin even in this
manner, the presenting part will be pressing upon the perinseum, and almost
or quite visible from below. If a vaginal examination is made in order to
determine the progress of the presenting part, a gradual diminution in the
distance between the latter and the perinseum can be determined. But here
we have to guard against a possible fallacy. In all cases of delayed labour
with strong uterine contractions the caput succedaneum hourly increases in
size, and bulges more and more downwards towards the perinseum. Conse-
quently, it is easy to attribute the diminished distance between the caput
and the perinseuni to the descent of the presenting part instead of — as may
be the case — to the increasing size of the caput. (For " Management," see
p. 189.)

Third Stage. — Duration. — The third stage commences with the birth
of the foetus, and ends with the expulsion of the after-birth. It is im-
possible to estimate its average duration, as the latter depends entirely
upon the manner in which the stage is conducted. If the expulsion of the
placenta is left to the natural efforts, the average duration is from two to
three hours. If, however, the usual method is adopted of waiting until the
placenta is detached by the uterine contractions and expelled into the
vagina, and then expressing it after the Dublin method, the average dura-
tion of the stage is from ten to fifteen minutes.

Phenomena.— rThe principal phenomena of the third stage are the con-
tinuance of intermittent contractions and permanent retraction of the
uterine muscle fibre, the detachment of the placenta, and the expulsion of the
latter, first from the contractile segment of the uterus into the lower uterine
segment or the vagina, and then from the latter position externally. It is
most convenient to consider the third stage as consisting of two periods. In
the first period, the placenta is detached and expelled below the contraction
ring ; in the second period, it is driven outside the genital passages. The
mechanism by which the placenta is detached from the uterus is still a
matter of some dispute. The most commonly accepted theory is that of
Schultze. He considered that the placenta was first partially detached
owing to the shrinkage of the placental site, which occurs as the uterus
contracts down after the birth of the foetus ; that then blood escaped from
the uterine vessels into the retro-placental space thus formed, and con-
stituted a haematoma, the pressure of which completed the detachment of
the placenta and drove the latter downwards into the membranes with its
foetal surface lying lowest. As a result, the placenta is the first part of the
secundines to leave the uterus, and, subsequently, as it descends still farther,
it pulls the membranes after it and so causes their detachment. Matthews
Duncan, on the other hand, considered that the placenta after its detachment
was expelled from the uterus with its lower border first, and that it passed
through the contraction ring as a button goes through a button-hole. Its
expulsion with the smooth foetal surface forwards, he considered to be due
to premature traction upon the cord. Schultze's mechanism usually occurs
in about three-quarters of all cases, but then there is frequently a slight
amount of traction upon the cord during the birth of the child.

The Edinburgh school, in the persons of Hart and Barbour, brings forward
two theories as to the cause of placental separation and expulsion, which
differ from the foregoing. Barbour considers that he has proved that the
placental site can be reduced to a space of four and a half by four inches,
without causing the separation of the placenta. He also considers that

LABOUE, STAGES AND DUKATION 149

if the uterus contracts firmly down upon the placenta it will tend to expel
the latter, and during this process separation will naturally occur. Accord-
ingly, he attributes the separation of the placenta to the diminution of the
placental site to an area less than four and a half by four inches, plus the
action of the uterus as a whole on the placental mass. Hart, on the other
hand, while agreeing that the main cause of the separation of the placenta
is disproportion between its area and the area of the placental site,
considers that the cause of the disproportion is. not the placental site
becoming smaller than the placental area, but its becoming larger than
the latter. His reason for his belief is as follows : — so long as the placenta
has either or both its blood supplies from the maternal or foetal vessels
intact, it can diminish or increase in size pari passu with the portion of
uterine wall to which it is attached. When, however, the supply from both
mother and foetus is cut off, the placenta can diminish pari passu with the
uterine wall, but cannot again expand as the wall relaxes. Consequently,
separation occurs during the relaxations of the uterus which occur in the'
third stage after the foetal circulation has
ceased — owing to the ligation of the cord
or other cause, and after the maternal
supply has been cut off by the retraction
of the uterus.

The descent of the placenta below
the contraction ring, i.e. the commence-
ment of the second period of the third
stage, can be recognised by certain
changes which take place (Figs. 13 and
14). They are as follows : —

(1) The funis lengthens. — As the
placenta leaves the uterus and comes ^^ /""\
to lie in the vagina, the cord will also ll „ ^■-^
descend, and there will be an increase no. is—Before the expulsion of the placenta
in the length of the portion which is (diagrammatic).

outside the vulva. This increase in length will be most easily recognised
if, when tying the cord, the ligature which is placed next the mother is
tied as close to the vulva as possible. It thus forms an indicator on the
cord, and enables any elongation of the latter to be readily detected.

(2) The fundus of the uterus rises upwards almost to the umbilicus. —
At the birth of the child the portion of the uterus above the contraction
ring sinks downwards into the thinned out lower uterine segment and vagina,
under the pressure of the abdominal muscles and of the controlling hand of
the assistant. Later, as the placenta is expelled from the uterus, it comes
to occupy the place where the body of the uterus formerly lay, and so dis-
lodges the latter upwards out of the pelvis. As a result the fundus rises
from its former position — slightly above the pelvic brim — to almost the
level of the umbilicus.

(3) The mobility of the uterus is increased. — This change also depends
upon the alteration in the position of the body of the uterus. When the
latter lay in the pelvic cavity with the placenta inside it, it was supported
all round by the walls of the . pelvis, and consequently it could not be
readily moved from side to side. As, however, it rises out of the pelvis this
support is lost, and consequently it becomes more mobile.

(4) The abdominal wall bulges forward above the pubis. — This change is
due to the presence of the placenta in the lower uterine segment or in the
upper part of the vagina. The placenta, lying in one of these positions,

150

LABOUE, DIAGNOSIS AND MECHANISM

Fig. 14.

pushes forward the structures in front of it, and so causes a prominence
above the pubis which is not unlike that caused by distended bladder.

The expulsion of the placenta from the vagina, if left to the natural

efforts, is a somewhat lengthy process.
There is no very efficient natural
mechanism for obtaining this expulsion,
as the unnatural position in which the
patient is placed, i.e. on her back in bed,
prevents her from forcing the placenta
out, by straining, as readily as she would
do if she could get into a squatting
position. Consequently the placenta
lies in the vagina for some time, until
it finally works its way downwards
helped by any contractions of the
abdominal muscles which may occur.
In consequence of the unnecessary delay
which such a tedious process would cause,
this period of the third stage is invariably
artificially shortened. The most usually
adopted way of doing this is by the method originated in Dublin during
the early years of the present, the nineteenth century, i.e. by substituting
firm pressure over the uterus for the natural efforts, and so by driving the
uterus downwards into the vagina effecting the expulsion of the placenta.

As has been mentioned, the loss of a certain amount of blood is almost
an invariable accompaniment of the third stage. The average amount is
said to be four ounces before the placenta is delivered, and six ounces with
the placenta and membranes (Dakin).

Constitutional Symptoms. — Immediately after delivery, the patient
experiences a marked sense of relief due to the almost complete cessation
of pain. The temperature may be slightly higher than during labour, while
the pulse-rate may be somewhat less than it was during the latter portion
of the second stage. The subsequent condition of the patient depends
entirely on the amount of blood which is lost. In some cases there may be
a slight increase in the pulse-rate and a depression of temperature of one
or two degrees, owing to the amount of blood lost, and to the chilling of the
patient, which may occur during the delivery of the after-birth and the
necessary cleansing of the parts. The degree of pain caused by the uterine
contractions is, as a rule, not very severe. (For " Management," see p. 192.)

-After the expulsion of the placenta
(diagrammatic).

Diagnosis and Mechanism of Labour

General Diagnosis of Normal
Labour ....

Physical Examination

Abdominal .
Vaginal
Bimanual .

General Mechanism of Normal
Labour .
Factors of .

Vertex Presentation —

General Principles of Me-
chanism . .

151

151
152
156

156

156
156

157

Flexion'

Internal Rotation

Extension .

Head Moulding .

Diagnosis and Mechanism in

Special Vertex Positions

Moulding .

Persistent Occipito - Posterior

Mechanisms .

Moulding .

Diagnosis and Mechanism in

Face Presentation

Moulding

159
161
162
163

164
165

165

167

168
169

LABOUB, DIAGNOSIS AND MECHANISM 151

Persistent Mento - Posterior

Mechanisms —

First Face Position . . 169

Second Face Position . .170

Third Face Position . .171

Fourth Face Position . . 171

Brow Presentations . .173

Diagnosis and Mechanism in

Podalic Lies . . .174

Diagnosis and Mechanism in

Transverse Lies . . .175

Spontaneous Delivery . .180

Diagnosis of Nokmal Labouk

In describing the various relations which the foetus and its parts may
assume to the pelvis of the mother and to one another, the following terms
will be used, namely, lie, position, presentation, and attitude.

By the lie is meant the relation of the long axis of the child to that of
the mother. The foetus may lie with its long axis approximately in that
of the mother, in which case the lie is a longitudinal one ; or the child may
lie across the mother's trunk, and is then said to be in a transverse lie.

In the case of a longitudinal lie the head may be directed downwards,
cephalic lie ; or the breech may be downwards, podalic lie.

The term position means the relation a given part of the foetus — the
one taken is usually on the posterior aspect — has to the anterior, lateral, or
posterior aspect of the mother.

In the case of the head presenting by the vertex, the posterior end
(occiput) may be directed to the front, occipito-anterior ; to the side, head
transverse ; or to the back of the mother, occipito-posterior ; or to some
other point on the circumference of the pelvic ring.

The word " orientation " is frequently used by French authors to express
this meaning, and is in fact a more exact and unambiguous expression of it.

Presentation is a term which has been used in a very loose way by
various authors. It really means that part of the foetus which is first
touched by the finger of the person making a vaginal examination.

If the child is in a cephalic lie it may present by the vertex, or by the
face, or by a surface of the head intermediate between these areas. Also,
in a podalic lie the feet or the breech may be the presenting part. Tyler
Smith defines the presentation as that part of the child which is " felt most
prominently within the circle of the os uteri, the vagina, and the ostium
vaginae, in the successive stages of labour."

The relations which the trunk, the head, and the limbs of the child have
to one another constitute the attitude of the foetus. This is considered
quite independently of any relation of the foetus to the maternal parts.

The usual attitude is one of flexion — the head is flexed on the trunk,
the thighs are flexed on the abdomen, and the legs on the thighs.

Or the head may be in a state of extension, as in face presentations ; or
the legs may be extended on the thighs, as in certain kinds of breech
presentation.

Physical Examination

In endeavouring to determine the relations of the child to its mother's
pelvis in order that the course of labour may be intelligently watched, and
any assistance, in cases where it is necessary, given to the greatest advantage,
the most satisfactory results will be obtained by pursuing a routine course
of examination in every instance.

The following plan should be adopted, and the sections taken in the
order given : —

152

LABOUK, DIAGNOSIS AND MECHANISM

Abdominal examination — Inspection

Palpation
Auscultation
Vaginal examination
Bimanual examination
Other points also, such as the shape of the bag of membranes, the escape
of meconium from the cervix, and any peculiarities in the way the liquor
amnii comes away after rupture of the membranes, are to be observed,
since they may assist in the diagnosis.

Abdominal Examination. — For this purpose the woman must lie on her

Fig. 15. — Graphic representation of parts felt on abdominal palpation in the case of cephalic lie
(first vertex position).

back in as comfortable a posture as possible, with the abdomen thoroughly
exposed to view.

The bladder must be empty, a catheter having been used if necessary,
and the bowels should have been well cleared out.

Inspection and Palpation. — The uterus at the beginning of the exam-
ination may be found in a state of contraction or of relaxation. In either
case valuable evidence can be gained.

During Contraction. — If it is tense, the general outline of the uterus
can be readily seen and felt, and its long axis made out ; but the parts of
the child cannot be recognised.

The lie of the child, longitudinal or transverse, however, can be
ascertained ; and at the same time, although it may not be a question of
importance as regards the future mechanism, the presence of a fibroid
tumour in the accessible parts of the uterus would probably be discovered.

Deviations of the uterus from the normal axis, which, as will be seen
later, influence the mechanism of labour, are easily made out, and steps
may be taken now or later to diminish or change the side of any such
deviation if it is likely to interfere with the normal course of labour.

LABOUK, DIAGNOSIS AND MECHANISM

153

During Relaxation. — It is when the uterus is relaxed, however, that the
most valuable information can be gained. The exact relation of the child
to the mother's pelvis, and its attitude, can in the large majority of cases be
distinctly made out.

Position of Observer. — It is best to stand at first on the right hand of

the patient, looking towards her head. The hands should be laid flat on her
abdomen, one lying over each side of the uterus. Each hand thus makes
counter-pressure against which the other can work (Fig. 16).

Supposing the child to be in a longitudinal lie, and that the hands fall
about the middle of the uterine length, the first thing noticed in a case
favourable for examination is that on one side, the left (of the woman) in
the most common position of the child, there is a firm even surface ; on the
other side the feeling is that of a somewhat soft elasticity. The resistant
feeling is caused by the underlying back, the softer one is produced by a
space filled with liquor amnii, existing between the two incurved poles of
the foetus. If the two hands are now moved up higher on the abdomen,

Pig. 17.

still lying opposite to one another (Fig. 17), the back of the child can be
traced up to the fundus uteri, feeling pretty much alike in all its length,
and following the curve of the fundus on merging into the breech ; while on
the right side of the mother the left hand is able to make out some irregular
knobs, which are the feet, and perhaps the knees of the child. The limbs
may often be felt and seen to move, both by the observer and by the mother.
It will, be noticed that the mergence of back into breech as the right hand

154

LABOUK, DIAGNOSIS AND MECHANISM

is moved upwards is an imperceptible one, differing considerably from the
sensation conveyed where the head is at the fundus.

An attempt may now be made to feel the head of the child as it lies on the
brim (multipara), or slightly dipping into it (primigravida), by placing the

Fig. IS.

right hand on the abdomen, just above the level of the symphysis (Fig. 18).
The thumb and middle finger will usually be able to grasp the base of the skull,
and the hardness, roundness, and mobility of the head can be recognised.

The head can be more clearly identified and its position made out by the
observer's next turning so as to look towards the woman's feet, using his
hands in combination as before. To grasp the head between the|tips of the
fingers they will have to be pressed somewhat deeply downwards1- and back-

Fig. 19.

wards towards the pelvic inlet — a superficial palpation will yield no results
of value. When the head is felt to be well grasped by the tips of the
fingers it can in the usual attitude of the child be made out without much
difficulty that the back, traced from above, slopes into the nape of the neck
without any abrupt curve ; whereas on the right side of the woman the
prominent forehead makes a fairly distinct relief from those parts of the
foetus, namely, the arms folded on the chest, to be felt just above it.

If the head is extended, as in face presentations, the occiput will be felt
to project somewhat abruptly from the curve of the back as this is traced

LABOUE, DIAGNOSIS AND MECHANISM 155

down ; but the chin of the child will lie pretty much on a plane with the
front of the child's body-surface. The arms are frequently not clearly recog-
nised. If they are, there is no mistake as to which way the child is facing ;
but it may be remembered that the lower limbs, which can, if any
part can, always be made out, point to the anterior surface of the child.

In performing any of the above manipulations the best results are got
in a multipara whose abdominal walls are thin, and who is able to bear such
an examination without tightening her abdominal muscles. In cases where
these conditions are not found the foetal parts can often be recognised, if
instead of making steady pressure on the parts under the hands, this
pressure is made in slight jerks, in the same way as a liver may be mapped
out in an ascitic abdomen. The slight jerk overcomes momentarily the
resistance of the interposed layers, whether they be of elastic tissues or of
fluid, though of course more perfectly in the latter case. It will be found,
however, that with practice the consecutive sensations obtained by " dipping "
all over the surface of a uterus, even if there be some obstacle of the kind
named in the way, are mentally combined into a fairly reliable impression
of the lie and position of the child.

The importance of abdominal examination of pregnant and parturient
women cannot be overestimated. In fairly practised hands they give more
reliable results than are to be obtained from vaginal examinations alone,
though it is not recommended that abdominal examinations should be con-
sidered sufficient for practical work. With the desire of avoiding all
possibility of septic infection, a long series of cases were examined at one
lying-in hospital by the abdominal method alone, and no accident is
recorded ; but it is evident that such a condition as prolapse of the cord,
which gives no sign externally save that of slowing of the foetal heart if
compression of the cord is becoming fatal, would remain unrecognised if this
means of examination only were used.

The results of abdominal examination in each kind of lie, position, and pre-
sentation will be given in describing the special mechanism belonging to each.

Auscultation. — -This method of examination is applicable in practice
to the abdomen alone ; for though attempts have been made to utilise it by
the vagina, and a stethoscope has been contrived for the purpose, no informa-
tion of value can for many reasons be obtained by this route.

For the purpose of diagnosis of the relations of the child to the pelvis,
the only sound which is of any value is that of the foetal heart.

In the commonest position of the child in the cephalic lie, namely, when
it lies with its head flexed and the occiput pointing to the mother's left
and somewhat forwards, the foetal heart is best heard over a point about the
middle of a line joining the left anterior spine to the navel ; that is, at the
spot where the right upper part of the child's back lies in contact with
the uterine wall immediately under the abdominal parietes.

A layer of fluid between the child and the surface cuts off all possibility
of hearing the sound ; and this may be heard better over parts of the child,
even if they are more remote from its thorax, so long as such parts are
touching the uterine wall in front, than over the cardiac area of the child if
this be separated by fluid from the end of the stethoscope. The heart-
sounds of the foetus are therefore never heard over the front of its chest
unless it is in an attitude of extreme extension, such as is found in
presentations of the face.

The sounds are more distinctly heard when counter-pressure is made on
the opposite side of the uterus to the stethoscope, so as to bring the con-
ducting; surface into closer contact with the abdominal wall.

156 LABOUE, DIAGNOSIS AND MECHANISM

Vaginal Examination. — By vaginal examination the condition of the
pelvis and its contents are more or less distinctly made out according to
the stage of labour. It is really complementary to the abdominal examina-
tion, and should not be undertaken until as much as possible has been
already determined by the latter means.

As far as the mechanism of labour is concerned, and we are dealing here
with this alone, the points to be observed are the relations of the parts
within the canal of the cervix or vagina as the case may be to the pelvic
walls and to one another.

Thus it is ascertained how far the bag of membranes, if this exists,
protrudes in front of the presenting part ; whether the cord is presenting
or prolapsed ; what the presenting area is ; and its relations, in position and
size, to the pelvic walls.

After a careful abdominal examination there is no difficulty in very
rapidly making one's self quite certain on all these points. If no present-
ing part can be discovered it will easily be decided to what cause this must
be referred, for a transverse lie will have already been made out by the
abdomen, as will a high-lying breech or a hydrocephalic head ; and in the
absence of these conditions placenta prtevia will be thought of and recognised.
(Another cause of absence of presenting part, namely, rupture of the uterus
and escape of the foetus into the abdominal cavity, need not be considered
here.)

If necessary to complete diagnosis, the whole hand may be introduced
into the vagina under an anaesthetic.

As a matter of course antiseptic measures must be rigidly practised.

Combined Examination. — A most accurate determination of the mechan-
ism to be expected can be made by the bimanual method. The part
occupying the pelvis or its inlet can be held between the fingers of the
opposing hands, and all or nearly all its surfaces explored and recognised.
In the case of the head the amount of flexion, and the relative size of the
head and brim, can be infallibly demonstrated and the previous diagnosis
confirmed. In breech cases the presenting part can be brought within
easier reach of the vaginal finger, and its disposition clearly ascertained ; or
if a shoulder is presenting this can be identified.

The other points in diagnosis may be mentioned, namely, the escape of
meconium, which, in any quantity and unmixed with liquor amnii, strongly
suggests a breech presentation ; and the discharge of an excessive amount of
liquor amnii, which may be due to hydramnios and may also indicate a
podalic he, or may mean a transverse lie or a contracted pelvis. In this
category comes also a prolapsed cord, as showing that the presenting part
does not accurately fit the pelvic inlet.

Mechanism of Noemal Labour

The mechanism of labour, by which is meant the movements which the
foetus makes in its passage through the parturient canal, is a process almost
entirely belonging to the second stage. Some attention, however, will have
to be paid to the first stage, that of dilatation of the cervix, and even to
periods anterior to this. Three factors combine to constitute the mechanism
of labour. They are : —

A. The expelling force.

B. The passage through which expulsion is effected.

C. The Body to be expelled.

The expelling force is provided by the contractions of the uterine

LABOUE, DIAGNOSIS AND MECHANISM 157

muscle, the muscles of the vagina, and those of the abdominal walls, as has
been already described.

This force must act, as far as it is an effective one, in the axis of that
portion of the canal occupied by the part of the child actually engaged in it.1

The passage consists of a short tube with a bent axis (axis of the par-
turient canal). The walls of this tube vary in rigidity at different cross-
sections ; and the shape of its cross-section, taken at right angles to its axis
at that level, varies at different points along its length in a definite manner.
(See " Physiology of Labour," p. 137.)

The tody to he expelled consists of two ovoids, the trunk and the head,
connected by a joint which allows of almost " universal " movement. Of
these two ovoids the head is comparatively rigid, the body very plastic.
The head is therefore the more important of the two ovoids in the matter of
mechanism.

There is, however, another property of the foetus, and that is its elasticity.
When the head is fully flexed, for instance, the child has a certain tendency
towards extension ; and on the other hand, when the foetus is extended there
is a still greater tension produced in its body which makes for flexion. This
curve-tension, as it may be called, has not received any attention from writers
on obstetrics ; but it has, as will be shown, an important influence in the
mechanism of labour. The elasticity of the child is mainly due to its
muscular tone, and in a less degree to the ordinary elasticity of the bones,
ligaments, fasciae, and other connective tissues.

The fit of the child to the pelvis is a close one, even when the two
ovoids of which it consists are accommodated to the passage in the most
advantageous way.

The most advantageous way is that, in the first place, the long axis of
the child shall lie approximately in the axis of the passage — delivery in a
transverse lie is impossible.

This being obtained, there remain the sections of the foetus at right
angles to the long axis to be adapted in the best way to the cross-sections
of the passage; that is, the width of the shoulders has to go into that
diameter of the canal where there is most room for it ; and still more im-
peratively, the longest of those diameters of the head which lie across the
canal must find themselves in the widest diameters of that part of the
canal in which they lie, or labour will be delayed or arrested.

Since the tube has its greatest diameters at one level transverse, at
another oblique, and at another antero-posterior, these longest diameters of
the head and trunk will, as the child descends, be constantly endeavouring
to follow them.

This endeavour on the part of the foetal mass to find the path of least
resistance is the cause of the mechanism of labour.

Presentations of the Vertex

General Principles of Mechanism. — The movements of the child in the
commonest kind of presentation, namely, that of the vertex, and in the posi-
tion in which the head lies with the occiput directed forwards and to the left,
will now be described in somewhat full detail. They will serve as a
standard, and the points in which other mechanisms agree with or differ
from this type can then be easily understood.

1 The head is said to be " engaged " in the pelvis when it has entered sufficiently for its
movements to be influenced by the pelvic walls ; and any other part of the child is ''engaged "
in that region of the pelvis which is influencing the movements of the said part by its shape.

158

LABOUK, DIAGNOSIS AND MECHANISM

The child is found in the cephalic lie in about 96 per cent of all cases at
the end of pregnancy. Of cases in the cephalic he about 75 per cent are
presentations of the vertex in the position just mentioned. There are three
main reasons for this. They are (1) the position of the centre of gravity of
the foetus at term ; (2) the relative shapes of the foetus and the uterus ; (3)
the movements of the foetus in the uterus.

(1) The centre of gravity of the child at term is found to lie about the
level of the shoulders, rather to the right side on account of the liver lying
to the right, and nearer to the back than to the front of the thorax. A
foetus suspended in a fluid of its own mean specific gravity would thus tend
to lie slightly on its right side with its head downwards.

The uterus is inclined to about an angle of 60° with the horizon when

Utero-vesical pouch —
Symphysis —

First Lumbar

Douglas' Pouch

Anus

Vaginal and urethral
orifices

Fig. 20.— Uterus at term.

the woman is in an upright posture, and in addition its anterior surface is
rotated slightly round to the right. Thus the left side of the front of the
lower segment of the uterus is the lowest part of its cavity. In consequence
the head tends to fall into this part, with the right shoulder in front of it,
that is, into the position above mentioned. The natural attitude of the
head is one of partial flexion, and so the vertex comes to lie lowest.

(2) Relative shapes of the foetus and the uterus. — The widest part of the
uterus is the fundus, and the widest part of the foetus is its breech, and so
the breech tends to lie in the fundus. As a proof of the value of this as a
cause it may be mentioned that in the case of hydrocephalic children, in
which the head-end is the larger, the child lies with its breech downwards
far more commonly than where it is normally shaped.

Also, it will be remembered that when the uterus is relaxed there is a
well-marked convexity of the posterior uterine wall forwards, owing to the
projection forwards of the lumbar spine. The normally flexed child has its

LABOUK, DIAGNOSIS AND MECHANISM 159

concavity on its ventral surface, and in consequence obtains the most com-
fortable fit to the uterus by lying with its dorsal surface forwards.

(3) The movements of the foetus in the uterus are mainly of its legs ;
and in any case the legs, acting at the end of the body, will have more
influence than the arms in bringing about changes of lie. The child up to
the seventh or even the eighth month is able to change its lie without much
difficulty, as is well known.

If we take a child lying with its feet downwards, any sudden extension
of its lower limbs will bring them against the brim of the pelvis and tend
to throw the lower end of the body upwards. If this displacement is so
great as to bring the child into a transverse lie, the shape of the uterus will
soon tend to convert this into a longitudinal one, either cephalic or podalic.
If the child falls back into its original lie, the same process may be repeated
again and again ; but if the longitudinal he happens to be the cephalic the
child with its legs uppermost has nothing resistant to kick against, and
movements of its legs will have little effect in moving its lower end away
from the fundus.

The child is then, to start with, lying with its head flexed and its occi-
put forwards and to the left. It does not, in ordinary cases, engage till the
membranes have ruptured.

At this moment a diameter near the occipito-frontal diameter is lying in
the plane of the brim.

The expelling force at this stage, that is, after rupture of the mem-
branes, consists in the uterine contractions, exerted, since the fundus uteri
is not yet in contact with the breech of the child, as a general intra-uterine
pressure acting over the whole surface of the child excepting the vertex,
which is in contact with the lower uterine segment.

Downward pressure comes to bear on the area of the vertex which
overlies the os and is therefore unsupported, and this pressure is acting in
the axis of the uterus practically through the centre of the child's head.

Flexion. — The head is lying with a diameter near the occipito-frontal
across the lower uterine segment. In this relation to the parturient canal
the head is comparable to an egg lying in an elastic tube with its long axis
not coinciding with the axis of the tube. If the egg is moved backwards and
forwards, and friction reduced as far as possible by lubrication, it will soon
come to lie with its long axis pretty exactly in that of the tube, and its
small axis across it. In the case of the head the
long axis is the mento-vertical, and any move in
the direction of accommodation, such as is made
by the egg, would mean, in the state of partial
flexion in which the head is now, a further flexion.
The head then becomes more flexed, and the
suboccipito- frontal diameter, the smallest available
diameter of the head, owing to the attachment of
the head to the trunk, takes the place of one
nearer the occipito - frontal, and lies across the
tube (Fig. 21).

This movement of flexion is assisted by the
obliquity of the uterus. The uterus is, in the
greater number of instances, inclined to the IG'Pressure of Avails oS-
right, and any pressure acting on the base of £g"d! on moderately flexed
the skull, and not at right angles to its surface,

will tend to depress that end of the skull towards which the line of
pressure is directed. In the position of the head under consideration the

160

LABOUK, DIAGNOSIS AND MECHANISM

occiput is to the left, and therefore becomes depressed ; that is, the head is
flexed. It is likely that the uterine obliquity has comparatively little
power in this direction before the fundus comes into contact with the
breech, and foetal-axis-pressure 1 comes into play ; but that it has some is
shown by the fact that left dorsal positions predominate in the proportion
of about 9 to 3 in vertex presentations, whereas in face presentations
the proportion is only 4 to 3. This shows that with the uterus in the
usual inclination to the right there is a greater tendency for the head to be
flexed in left dorsal positions than in those where the occiput is to the
right ; and a greater tendency for it to become extended (face presentation)
in right dorsal positions than in left (Fig. 22).

Still, the question of flexion or extension has in normal cases been
decided before the head engages, and engagement in practically all cases pre-
cedes the establishment of foetal-axis-pressure. But when the liquor amnii
has drained away sufficiently to allow the axis-pressure to act, there appears

Fig. 22. — Effect of obliquity of uterine axis on head at
brim. O, occipital ; P, frontal end.

Pig. 23. — Postal-axis-pressure on
slightly flexed head.

an additional factor in retaining and possibly increasing the flexion of the
head. For now the axis-pressure acts through the spinal column on the
base of the skull at the condyles. A line continuing the direction of this
pressure through the condyles to the level of the centre in bulk of the head,
falls when the head is only a very little flexed somewhere between the
centre of the head and its posterior end (Fig. 23). The occiput is thus
further driven down. The occipital end of the head under the circum-
stances is therefore the first part of the head to encounter the resistance of
the pelvic floor, and to be influenced by its slope.

If a vaginal examination is made after the biparietal diameter has passed
the brim, and before the head has come into relation with the pelvic floor,
the first part touched is a point somewhere near the posterior upper angle of
the right parietal bone. The sagittal suture is further back in the pelvis,
and appears to lie close to the sacrum. The biparietal diameter is therefore
oblique as regards the plane of the outlet of the pelvis, which is practically
a plane at right angles to the axis of the vaginal canal. Naegele" observed this
obliquity, and came to the conclusion that the biparietal diameter passed the
plane of the brim with the sagittal suture nearer to the sacrum than to the

1 Fcetal-axis-pressure. — This is a downward pressure exercised by the fundal end of the
uterus on the foetus in the long axis of the latter. It is made possible by the stiffening of
the child produced by the contraction of the circular fibres of the uterus. It occurs after the
greater part of the waters has drained away, and the fundus comes into contact with the breech.

LABOUE, DIAGNOSIS AND MECHANISM

161

pubes ; and he described this as the relation of the head to the brim in
normal labour. It is, however, not so, for the head passes the brim with its
biparietal diameter lying in the plane of the brim. The explanation is that
the head continues to lie in the same relation to the plane of the brim for
some little distance after it has passed through the brim, and must therefore
lie obliquely to the plane of the outlet (to which plane the results of a
vaginal examination are referred), and this is nearly at a right angle with
the plane of the brim.

The obliquity of Naegele is an important part of the mechanism of

Fig. 24. — Relation of head to finger when occiput lies to the left.

labour in certain forms of contracted pelvis. It is known also as Anterior
Parietal Obliquity.

Internal Rotation. — Owing to the shape of the pelvis, whose widest
diameter in the cavity is the oblique (5 inches), the suboccipito- frontal
diameter of the head (4|- inches) turns into the oblique, in which it already
approximately lies. This movement of rotation on the axis of the fetus
is performed in the main by the head alone, though the shoulders take a
certain share in it. Eotation in the pelvis is called inteknal eotation to
distinguish it from a rotation of the head, which occurs after this part has
escaped from the vulva, and is no longer under the influence of the maternal
parts.

The head, descending a little lower, brings its occipital end into contact
with the left half of the pelvic floor. This slopes inwards and downwards,

VOL. VI 11

162 LABOUK, DIAGNOSIS AND MECHANISM

and the occipital end of the head glides along its surface inwards and down-
wards to the anterior edge of the pelvic floor, thus finding its way under
the pubic arch, in the middle line almost. The occiput by this movement
along the pelvic floor carries on the rotation already begun till the sub-
occipito-frontal diameter is in the antero -posterior diameter of the outlet.
This, it will be remembered, is the widest diameter (5 inches) of the outlet,
and the suboccipito- frontal diameter would naturally tend to rotate into
this, the oblique and the transverse diameters of the outlet being respectively
4| inches and 4 inches, even if it were unaided by the slope of the left half
of the pelvic floor.

This movement of internal rotation may be put in another way, perhaps
more simply. Again, comparing the foetal head to an egg in a tube, the
long axis of the egg corresponding to the mento-vertical diameter of the
head, and the short axis to the suboccipito-frontal diameter, then an egg
passing down a curved tube, like the lower end of the birth -canal, and
having started with its long axis lying somewhat obliquely to that of the
tube, would tend to place this long axis in exact coincidence with the axis
of that part of the tube in which it happened to lie, and one of its poles
would first emerge from the lower end.

If the head were not attached to a trunk the mento-vertical diameter
would come to lie exactly in the axis of the lower end of the genital canal ;
but the shoulders are now in the brim, and are lying in the left oblique
diameter ; consequently there is a twist of the neck produced by the head
rotating towards the antero-posterior diameter, and the tension caused by
the twist prevents the rotation from being quite complete.

There is another reason for the incompleteness of the rotation. It will
be seen later that the head in passing through the tightly-fitting tube of
the parturient canal becomes moulded — that is, squeezed and diminished in
whatever diameters happen to lie in the cross -section of the tube, and
lengthened in those diameters which coincide with the length of the tube.
While the head is lying obliquely as it engages, the poles of its ovoid, after
moulding, will not be the anatomical poles of the mento-vertical diameter,
but in the position and mechanism under consideration, those of a diameter
whose posterior pole is to the right of the middle of the vertex, and whose
anterior pole is slightly to the left of the middle of the chin. This is the
real ovoid with which we have to deal as the head passes under the pubic
arch ; and its lower pole, the point to the right of the middle of the vertex,
is the one which will lie in the centre of the canal, and will first emerge
from the vulva.

Extension. — It will be remembered that at the level of the pelvic floor
the posterior wall of the genital canal takes a rather sudden bend forwards,
and the axis has a corresponding bend. In consequence of this the path of
the head is changed from one in the axis of the pelvic brim to one in that
of the pelvic outlet. Now the trunk is still lying in the upper part of the
parturient canal, and is therefore in the axis of the inlet. Therefore the
head makes now a different angle with the trunk from the one existing
before it entered the lower part of the canal. Since its dorsal surface is
looking forwards the head necessarily becomes less flexed than before, and
finally extended. The nape of the neck is at this time applied to the back
of the symphysis, and its movement along this surface, which is the inner
side of the curve, is very restricted compared to the large movement made
by the anterior part of the head along the posterior wall of the canal formed
by the pelvic floor and perinseum. The chin probably leaves the sternum
to some extent during this extension.

LABOUB, DIAGNOSIS AND MECHANISM

163

The movement of extension begins to take place before the head has
rotated into the nearly antero-posterior diameter of the canal, and there is on
this account some inclination of the head towards the child's right shoulder.

As the head continues to advance, following the still curving axis of the
canal, it becomes more extended, and the occiput moves upwards and for-
wards in front of the symphysis until the chin has escaped over the anterior
border of the perinaeum, and the neck alone occupies the orifice of the
vulva. The head is now out of the control of the canal, and any further
rotations of it are produced by the influence the diameters of the canal
have upon the shoulders.

The shoulders entered the pelvis with their bis-acromial diameter at
right angles to the occipito-frontal diameter of the head, and therefore in
the left oblique. They descend in this
diameter till they come to the pelvic floor.
The posterior shoulder then slides along the
left half of the floor backwards till it lies in
the bottom of the gutter formed by the two
halves of that structure, and, the antero-
posterior diameter of the pelvic canal being
at this level the largest of any, the bis-
acromial diameter rotates into it.

Now at the moment at which the head
clears the vulva the shoulders are still in
the left oblique, and the natural movement
of the head to place itself at right angles
with their width causes it to rotate immedi-
ately after emergence so as to face slightly to
the right (Fig. 25). This first rotation is made
very frequently with a jerk. Then as the
shoulders rotate completely into the antero-
posterior diameter of the outlet the head
moves farther round, so as at last to face
the mother's right thigh. This is the movement of external rotation or
Restitution, the latter name indicating that the head is now restored to the
position it had at the moment of entering the pelvis, that is, facing to
the right.

The delivery of the shoulders takes place in the same kind of way as
that described for the head. The anterior shoulder appears first below the
symphysis, and there forms a centre round which the posterior shoulder
revolves. Eoth shoulders are born practically at the same time.

The arms are folded across the chest with the hands under the chin.
The upper part of the thorax now lies in the outlet and the lower part in
the brim, so that there is some lateral flexion of the trunk.

The hips come down in much the same way as the shoulders, their
bitrochanteric diameter turning into the antero-posterior diameter of the
outlet.

Moulding of the Head. — During the passage of the head through the
birth-canal some of its diameters become altered owing to the considerable
pressure to which the head has been exposed. The different ways in which
alterations of the shape of the head by pressure are permitted by its struc-
ture have been already explained.

The head passes through the canal with its longest axis, the mento- vertical
diameter, coinciding with the axis of the canal as nearly as the attachment
of the trunk permits. This would mean that all diameters at right angles

Fia. 25. — Relations of child to pelvis
during delivery of shoulders. (From
Winckel's frozen section.)

164 LABOUK, DIAGNOSIS AND MECHANISM

to this undergo compression if the coincidence were exact. Such is, how-
ever, not the case, for the leading point of the head is not found on the
sagittal suture, but on the right parietal bone close to the suture. The
compression takes place in a series of rings bounding planes at right angles
to the line joining this point to the chin. Lengthening takes place along
this line, and the head is obliquely distorted.

When the other positions of the vertex are considered it will be seen
that when the left parietal bone is to the front, in the second and fourth
positions, the end of the new long axis of the head is shifted to the left side
of the vertex.

Each mode of delivery of the head has, according to the relations pre-
vailing between the head and pelvis, a special moulding. These varieties
will be described in order after each variety of mechanism.

Diagnosis and Mechanism in Special Vektex Positions

First Vertex. — This is the one already described.

Diagnosis. — The occipito- frontal diameter is nearly in the transverse
diameter of the brim with the occiput a little forwards. Per abdomen,
the back of the child and the occiput lie to the mother's left, and the
foetal heart is heard on this side a little below the level of the navel. The
limbs are to the right.

Per vaginam, the woman lying on her left side, the sagittal suture is
felt through the sufficiently dilated os to run downwards and forwards, and
to end in the posterior, triradiate fontanelle. The anterior fontanelle may
be felt at the other end of the suture ; and possibly the right ear, with the
pinna directed downwards and forwards, can be reached.

Mechanism. — The head passes the brim, becoming more flexed. It then
rotates completely into the right oblique. As it descends the occiput is
directed towards the middle line, thus coming to the front, and passes under
the pubic arch. The suboccipito-frontal diameter now lies in the antero-
posterior diameter of the outlet very nearly. The nape of the neck is
pressed against the lower border of the pubic arch, and the birth of the
head is completed by extension. The shoulders come down in the left
oblique, the right shoulder being in front.

When the head has completely escaped the face makes a small move-
ment towards the mother's right thigh, and this movement is continued as
the shoulders rotate into the antero-posterior diameter of the outlet ; so that
the head lies at the end of restitution, with the face and occiput squarely
to right and left respectively.

Second Vertex. — In this case it is only necessary to substitute left for
right throughout the above description of the first vertex mechanism. The
sagittal suture, being in the left oblique, runs upwards and forwards.

Third Vertex. — The occipito-frontal diameter lies in the right oblique
nearly, with the occiput backwards.

Diagnosis. — Per abdomen, the back of the child lies to the mother's
right, and the limbs to her left. The foetal heart may be slightly more
difficult to hear in this position, since the back of the child is directed
rather away from the anterior abdominal wall. It is heard in the same
place as in second vertex positions.

Per vaginam the sagittal suture runs downwards and forwards as in the
first position, but the posterior fontanelle is found at the end of the suture
near the back of the mother's pelvis.

Mechanism. — The head descends as before, and on meeting the pelvic

LABOUK,- DIAGNOSIS AND MECHANISM 165

floor rotates through three-eighths of a circle to the same place as in second
vertex positions. The case then proceeds as if the position had been a second
vertex originally. It is thus said to have been " reduced " to a second vertex.

Fourth Vertex. — The occipito- frontal diameter lies nearly in the left
oblique diameter with the occiput backwards.

Substituting left for right the description of the mechanism of the third
vertex will answer for this. The sagittal suture runs upwards and for-
wards, the posterior fontanelle being towards the back of the mother's
pelvis. The head rotates so that it lies in the same position as if it had
begun by being a first vertex. It is therefore " reduced " to a first vertex.

The mechanisms of the first and fourth, and of the second and third
positions, respectively, are the same except for the fact that in the two
where the occiput lies backwards the rotation by which it comes to the
front is one which describes three-eighths of a circle, instead of, as in the
occipito-anterior positions, only one-eighth.

Moulding. — The way moulding in vertex positions is brought about has
just been described. The diameters reduced are those at right angles to
the long axis of the head, one near the mento-vertical. In all cases the
suboccipito- frontal, suboccipito-bregmatic, and biparietal are diminished,
and the mento-vertical lengthened. The occipito-frontal is in nearly all
cases diminished somewhat. In first and fourth positions the prominent
part of the vertex is on the posterior superior angle of the right parietal
bone, and over a varying area around this ; in the second and third
positions the prominence is on a corresponding area on the left side. The
caput succedaneum is over the prominence in each case.

The moulding in these, as in other vertex cases to be immediately
described, is assisted by the movements of the flat bones of the vault on
one another. Under the compression of the resistances encountered by the
head their edges overlap to varying degree. The bone most pressed upon is
the posterior parietal bone ; that is, in first and fourth positions the left ;
and in second and third, the right. In consequence of the pressure the
posterior bone is flattened and slides under the anterior one. Since the
frontal and occipital bones are attached to the base of the skull, and so
cannot move so freely, they always go under the edges of the parietal bones.

General Character of Labour. — In the above mechanisms the course of
labour may be considered as absolutely favourable for mother and child.
Other presentations and positions have in their mechanisms elements which
modify the prognosis for either mother or child, or both.

Peksistent Occipito-Posterior Mechanisms

In certain cases beginning with the occiput backwards (third and fourth
vertex) the labour does not result in a reduction of these positions to
second and first respectively, but the head is born with the face still
looking to the pubes. This occurs in rather more than 1 per cent of vertex
cases.

The Cause of this irregularity is want of flexion. Flexion to a sufficient
degree, as has been shown, is necessary to bring the occiput down low
enough to be the first part of the head to come into relation with the pelvic
floor. For if this does not happen there is no more reason why the occiput
should rotate to the front than that the forehead should, since both ends of
the head ovoid reach the floor of the pelvis at the same time, and both are
equally directed forward by the slopes on which they impinge. _ Further,
there is, owing to the absence of flexion, no longer the suboccipito-frontal

166 LABOUE, DIAGNOSIS AND MECHANISM

diameter of 4 inches to easily rotate through the transverse diameter of
the pelvic cavity (4| inches), but the occipitofrontal of 4| inches has now
to be reckoned with. This cannot move through the transverse, and so
comes to be acted on by the shape of the pelvis at this level. The direction
of least resistance for it to move in is for the occiput to rotate into the
hollow of the sacrum.

Want of flexion is brought about in several ways. It is in some
instances due to one or other of the causes which, when acting to a far
greater extent than at present, produce face-presentations. Thus a slightly
contracted pelvis may have just enough want of space in its antero-posterior
measurement at the brim to retard the biparietal diameter, which is near
the hinder end of the head, for a time, and to allow the forehead to come
down more than is normal. The obliquity of the uterus may inter-
fere with the necessary amount of flexion, if the inclination happens to be
such that the line of the expelling force is directed along the abdominal
surface of the child ; as when the uterus has its normal obliquity to the
right and the head is lying with its occiput to the right (see Fig. 22, p. 160).

Flexion is apt to be interfered with in all cases of occipito-posterior

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-Third vertex of same pelvis,
diameter gripped.

Biparietal

Pig. 26. — First vertex. Pelvis of woman lying on her Pig
left side, seen from below. Biparietal diameter
free.

position more than in those with the occiput forwards, for after the head
has descended somewhat into the brim the child will lie with the promon-
tory of the sacrum fitting into the nape of its neck, and this tends to keep
the cervical spine extended rather than flexed. Still, in the large majority
of cases the causes leading to flexion manage to right this.

Also, as Herman points out, the sacro-cotyloid diameter in a normal
pelvis is less than the full oblique diameter. Now when the occiput lies
backwards the biparietal diameter occupies this sacro-cotyloid diameter, and
is more retarded than if it lay in the full oblique (Figs. 26 and 27). In
consequence flexion is somewhat interfered with, just as happens in similar
conditions in certain forms (elliptic brim) of contracted pelvis.

Diagnosis. — It can in most cases, by the unusual lowness of the anterior
fontanelle, be determined after the head has passed the brim and is engaged
in the cavity, that the occiput is going to rotate backwards. In well-flexed
cases this fontanelle cannot be reached at this stage without some difficulty.

Mechanism. — The description of this may begin when the occiput has
just rotated into the sacrum. The forehead lies against the back of the
symphysis. The head revolves round this, the occiput descending, prob-

LABOUE, DIAGNOSIS AND MECHANISM

167

ably much influenced by the foetal axis-pressure (see p. 160). The flexion
is in most cases assisted by a slight gliding upwards of the forehead behind
the pubes. As the head advances the occiput is pressed on to the pelvic
floor and perinseum, forcing the latter backwards and then passing over its
edge. Directly this has happened and the posterior pole of the head is free,
it moves backwards still farther over the perinseum till the nape of the

Fig. 2S. — Persistent occipito-posterior. (Moulding of head exaggerated.)

neck presses on the edge of the perinseum. The head is now born by
extension, and the forehead, face, and chin glide under the pubic arch.
The shoulders come down with the shoulder which was originally forward
still to the front.

Modified Mechanism. — There is a modification of this mechanism which
is occasionally seen. In it the forehead does not descend so low, and in
fact hitches on the upper edge of the symphysis. Flexion takes place as
before, but at a higher level. The head often remains fixed in these cases,
and labour is arrested. The vertex is found distending the perinseum to
some extent, and the cause of arrest is not readily obvious. When attempts
at delivery are made by the forceps the blades
are put on with a little more difficulty than
usual owing to the full diameter of the head not
being able to be grasped by them ; and when
traction is made the forceps invariably slips off.
The writer's experience, which is doubtless
shared by others, is that this condition of affairs
is a very common cause of a consultation being
necessary. The remedy for it is to carry the
handles of the forceps very far back while the
blades are being locked, and at the same time
to push the head bodily backwards by pressure
applied to the forehead above the pubes.

Moulding of the Head. — In the first described and commoner mechanism
the diameters compressed are the occipito-frontal and the biparietal. The
head is thus made rather dome-shaped, and the suboccipito-frontal and
suboccipito-bregmatic diameters are rather increased than diminished.

In the rarer form the head resembles the head after a very severe
occipito-anterior labour.

Fig. 29. — Rarer form of mechanism in
persistent occipito-posterior cases.

168 LABOUK, DIAGNOSIS AND MECHANISM

General Character of Labour. — The head is longer in passing through the
pelvis than in the last group where the occiput turns forwards (p. 164), as
it offers greater resistance to moulding along the lines in which moulding is
required ; and also there may be, as above mentioned, slight pelvic contrac-
tion. The fronto-occipital diameter (4| inches) distends the perinasum, and
makes rupture probable in multiparse, and certain in primiparse. There is
an increased risk of septic absorption, partly because of the laceration, and
partly because of the manipulations necessary.

The child is little, if at all affected, unless there is long detention of the
head. (For "Management," see p. 196.)

Mechanism in Face Presentations

The principles involved in the mechanism of labour when the head
presents by the face are identical with those already described as governing
the mechanism in vertex cases, the only difference being that different
diameters of the head are in relation with those of the pelvis.
The head is extended instead of flexed.

The general effect of this is that a somewhat less favourable relation
exists on the part of the head both to the forces expelling and to the
passage. The blunter face takes the place of the occiput, and therefore a
less effective wedge-action is brought about at the time when the head has
become the dilating agent — that is, after the membranes
have ruptured ; and further, the fcetal-axis pressure is
not applied so nearly at right angles to the base of
the skull as in the presentation of the vertex, but
impinges on the skull at a tangent.

Frequency. — The head presents by the face in about
one in three hundred of all cases.

Mode of Production. — The head becomes extended
for several reasons, which may act separately or in com-
bination.

1. Uterine Obliquity. — This has been shown in the

case of vertex presentations where the head lay in

the commonest position of the vertex, namely, with the

occiput to the left, and where the uterus had the usual

obliquity, namely, to the right, to distinctly favour

fig. 30.— Relation of head flexion. Where, however, one of these conditions is

sentation.iu face pre~ reversed, for instance where the occiput lies to the

right, the arrangement does undoubtedly favour

extension, and the head will be brought first into the attitude of

a brow presentation, and then into that of a face (Fig. 22, p. 160).

The explanation already given in reference to the causation of flexion
in vertex cases need not be made again at full length.

2. Flat Pelvis. — If the brim in this case is of the elliptical variety, the
biparietal diameter will have to lie in a diameter of the brim which will
to a greater or less degree retard its advance. This is a diameter to one
side of the conjugate, and roughly parallel to it, since in this class of
pelvis the head enters the brim in the transverse diameter.

The biparietal diameter lies nearer to the occipital end of the head than
to the frontal, and in consequence the occipital end will be retarded while
the frontal end is allowed to advance. The result of this is to extend the
head (see also p. 166).

3. Dead Child. — Dead children present by the face in a larger propor-

LABOUR, DIAGNOSIS AND MECHANISM 169

tion than living ones do. The reason of this is that the normal muscular
tone is wanting, and the head may reach the brim in any attitude ; and
then if there are other forces (obliquity of the uterus in a suitable direction,
for instance), which will tend to extend the head, a face presentation is
readily produced.

4. Other causes of far less importance sometimes bring about a face
presentation. A goitre may sometimes be large enough to cause extension
of the head by its bulk. It has been said that an unusually long head
(dolicho-cephaly) is very liable to present by the face. This is quite un-
certain, and. the type would have to be extraordinarily well marked to cause
this result.

Before entering on the detailed description of the mechanism in each
kind of face presentation, it will be well to point out the features wherein
face cases differ from those of the vertex.

The chin takes the place of the occiput in being the most advanced
part of the head, and the occiput comes last.

The submento-vertical diameter (4§ inches) takes the place of the
suboccipito-frontal (4 inches) in relation to the walls of the birth-canal. A
larger diameter has therefore to pass, and there is proportionate delay.

The chin does not project so far in advance of the general mass of the
head as the occiput does, and so does not so soon come under the influence
of the pelvic floor. In the case of the chin being behind, rotation forwards
takes place later in face presentations than rotation forwards of the occiput
in occipito-posterior vertex cases.

Moulding takes place with more difficulty than in vertex presentations,
for the whole hind-head has to be depressed on to the back of the neck.
This means more delay in the case of a closely fitting head and pelvis.

The Positions of face-cases are four, and are named according to the
direction of the chin. They are : —

1st, or right mento-posterior. The long diameter of the face is in the
right oblique diameter of the brim. This is called the first position, since
it is derived from the first vertex position by extension.

2nd, or left mento-posterior, in a similar way from the second vertex.

3rd, or left mento-anterior, from the third vertex.

4th, or right mento-anterior, from the fourth vertex.

In each of these cases the forehead in the face presentation lies in the
place occupied by the occiput in a vertex presentation.

It will be easy to remember the relations of the corresponding positions
of the vertex and face if it be kept in mind that the back of the child looks
in the same direction whether the case be one of face or vertex.

It may again be stated for the sake of clearness, that although in
naming the positions the forehead takes the place of the occiput, the chin
represents the occiput in the mechanical relations of the process.

Diagnosis and Mechanism

First Face Position. — Bight Mento-posterior. — This, being derived
from the commonest vertex presentation, is naturally the commonest
position of the face.

Diagnosis. — On abdominal examination the back of the child is found
lying to the mother's left : the limbs are rather prominent on the right
side. There is a sharp angle between the back and the occiput. The foetal
heart, if it is heard, is most easily audible on the same side as the limbs,
namely, the right. This is, of course, due to the extension of the neck and

170 LABOUE, DIAGNOSIS AND MECHANISM

the upper part of the thorax, which makes them He near to the uterine wall,
since the convexity of the foetal trunk is now on the anterior surface.

On vaginal examination, if the os is sufficiently dilated, some part of
the face is usually felt, most commonly the orbital and glabellar region.
The bridge of the nose is traced backwards and upwards (in the ordinary
obstetric position) to the mouth, where the alveolar ridges are felt, and
beyond this the chin. The right cheek is anterior.

Mechanism. — The head passes through the brim in the right oblique
diameter, becoming slightly more extended, and the chin impinges on the
pelvic floor. The child can now descend farther only by rotation of the
chin forwards, for its neck is as far extended as possible, and the tension of

its curved axis is very considerable.
It thus comes to have the relation to
the curve of the axis of the parturient
■\1| lifev I ' canal that an elastic rod whose natural

; --, , curve was one with the concavity

J " • N \ " backwards would have to a tube con-

"'*V;'' / , taining it whose curve was a forwardly
mi. \ concave one. In this case, if the tube
. allows of a certain amount of move-
ment on its axis on the part of the rod,
and there is little friction, the rod will
rotate on its axis until it lies with
its curve coinciding; with that of the
tube ; that is, with both their concave
sides facing the same way. It will
readily be seen that in the case of the
foetus the tendency will be for it to

Fig. 31.— Mechanism in first face presentation. The CODie to lie with its chin forwards, SO
curved arrow shows the direction of the chin- j_ 1 j_t_ • p j_i

rotation. as to relax the tension of the over-

extended head and thorax. The cbin
will be guided by the slope of the right half of the pelvic floor forwards
and downwards till it appears at and escapes from the under surface of the
pubic arch. This tendency of the chin to come forwards is less opposed by
the shape of the pelvis than in the case in those positions of the vertex
where the occiput lies behind, for the length of the face is less than the
occipito-frontal diameter, and it can turn through the transverse diameter
of the cavity without difficulty. The chin then rotates through three-
eighths of a circle, and the face comes to lie in the antero-posterior diameter
of the pelvic outlet. The angle between the chin and the neck now
" hitches " under the pubic arch, to use a convenient but rather incorrect
expression, and the bulk of the head is pushed forwards by the pelvic floor,
producing a movement of flexion. The face, forehead, vertex, and occiput
successively clear the perinseurn, and the head is born, the chin rising up
in front of the symphysis in the same way as the occiput does in vertex
presentations.

The head is now free to move on the shoulders. These have by this
time rotated into the right oblique diameter, the right shoulder being to
the front as at the beginning. The face therefore looks towards the
mother's right thigh, and restitution takes place exactly as in vertex
positions.

Second Face Position. — Left Mentoposterior . — The face here lies in
the left oblique diameter of the brim, with the forehead to the front.

Diagnosis. — The back of the child is to the right and the limbs to the

LABOUK, DIAGNOSIS AND MECHANISM 171

left. The angle between the back and occiput, felt per abdomen, is on the
right side, and the foetal heart, if heard, is on the left.

On vaginal examination the left cheek is anterior ; the bridge of the
nose can be traced backwards and downwards to the mouth and chin.

Mechanism. — The head descends, passing the brim in the left oblique
diameter ; and after that it follows, mutatis mutandis, the same course as
that just described for the first facial mechanism.

In the first and second facial positions it will be noticed that the chin
has to make a long rotation of three-eighths of a circle to reach the space
under the pubes, thus contrasting with the corresponding vertex positions, in
which the rotation of the occiput is the shorter one of one-eighth of a circle.
In the third and fourth facial mechanisms, on the contrary, the rotation of
the chin is a short one, while it will be remembered that the third and
fourth vertex cases undergo a long rotation.

Third Face Position. — Left Mento -anterior. — The face lies in the right
oblique diameter of the brim, with the forehead backwards.

Diagnosis. — The back of the fcetus is to the right, and the limbs to the
left. The foetal heart is heard on the left. The left cheek is to the front ;
the bridge of the nose can be traced forwards and downwards toward the
mouth and chin.

Mechanism. — As the head descends the mechanism is simple. The chin
is directed forwards, rotating through one-eighth of a circle, till it comes into
the sub-pubic space. The head is then born by flexion, as has been described
in the first facial position when it has reached this stage.

The shoulders are in the left oblique diameter of the pelvis, the left
shoulder being in front. As they rotate into the antero-posterior diameter
at the outlet the face undergoes restitution, and looks directly to the left,
just as in the third vertex position.

Fourth Face Position. — Eight Mento -anterior. — The position and
relations in this mechanism are the same as in the last- described one,
"left" being substituted for "right," and vice versa. The mechanism
corresponds.

If we now contrast the mechanism in vertex cases on the one hand with
that of face cases on the other, it will be seen that the following are the
most important points of difference : —

In vertex cases there is flexion at the beginning ; the third position
rotates into the second, and the fourth into the first. Delivery of the head
is accomplished by extension.

In face cases there is extension at the beginning ; the second position
rotates into the third, and the first into the fourth. The head is delivered
by flexion.

Also, in mento-posterior positions, reduction can, and usually does, occur
later than in occipito-posterior ones.

Moulding of the Head. — The head in face presentations does not lie
with its long axis so nearly parallel to that of the parturient canal as is the
case in vertex presentations ; and so, although the longest axis of the ovoid
is the one which is on the whole lengthened, the diameters which are
shortened are not exactly the same as in the vertex moulding. The
lengthening takes place along the fronto-occipital and mento-occipital
diameters ; the shortening along the cervico-vertical diameter, or one close
to it. The occipital region is compressed between the back of the neck and
the wall of the birth-canal, and is therefore squeezed into a rather sharply
pointed wedge.

There is, in face cases, a peculiar and somewhat unaccountable pro-

172 LABOUE, DIAGNOSIS AND MECHANISM

minence of the forehead, in spite of the fact that the face is compressed
along its vertical diameter. This is due to the greater firmness of the
frontal bone, which, in addition to the fact of its being of greater thickness
at its lower part than the other bones forming the vault of the skull, is also
really part of the base of the skull as far as its orbital portion is concerned,
and is therefore not easily bent.

The caput succedaneum is usually formed when the face is at the
vulva, or close to it, and lies near the angle of the mouth — on the right side
in first and fourth positions, and on the left in second and third positions.
If a caput is formed while the head is still within the os, or high up in the
canal, it will appear in the mento-posterior positions somewhere near the
left or right eye, according to which eye lies to the front. The tumour is
sometimes very large, and is not seldom the seat of much ecchymosis.

Persistent Mento-posterior Mechanism. — The chin sometimes fails to
rotate forwards, just as in the case of a posterior occiput. This is very rare,
for the mento-frontal measurement, which is about three and a quarter
inches, does not prevent rotation by its length in regard to the transverse
diameter of the cavity as happens in the case of the fronto- occipital
diameter in persistent occipito-posterior positions (p. 165). The chin comes
forward under the influence of the pelvic floor quite easily as a rule, even
if the head has descended well on to the pelvic floor before rotation is begun.

In addition to this, the curve-tension of the foetus has here a very
powerful effect. If the head descends deeply into the pelvis with the chin
still backwards, the extension of the head and neck is very considerable,
and the tension in the direction of flexion is very great. We have there-
fore the curved rod (p. 170) bent by the shape of the tube in which it lies
into a reversed curve. Given the comparatively unrestrained movement on
its long axis secured by the short mento-frontal diameter, the trunk of the
child will rotate on this axis as already described.

It is fortunate that reduction is so much the rule, for with an un-
reduced mento-posterior position in the case of a normal pelvis and head,
delivery cannot take place.

The reason of non-reduction is analogous to that of vertex cases. It is
due to insufficient extension, whereby the most favourable diameters are
not brought into relation with the pelvis. In other words, the presentation
is one very nearly that of the brow (see below), and a diameter near the mento-
vertical is thrown across the pelvis. Such a diameter will measure about five
inches, and will prevent forward rotation ; the chin will therefore move
backwards into the hollow of the sacrum.

There is a great difference between the state of things now present and
those which obtain in the case of occipito-posterior mechanisms. In the
latter the head flexes a little more, the occiput clears the perinseum, and
frees the head. Here, however, the anterior fontanelle is jammed against
the back of the pubes, and to enable the chin to clear the perinseum an
amount of additional extension of which the head is not capable is required.
For, as the base of the skull comes deeper into the pelvis, to enable this
extension to take place, it brings with it the neck, and after a little more
descent the upper part of the thorax. A wedge is thus endeavouring to
enter the pelvic brim which the latter is unable to accommodate, and
impaction results. To enable delivery to take place the head has to be
reduced in size by perforation. In some cases of small or dead children
the head has been able to extend sufficiently to permit the chin to escape
over the perinseum, and allow of flexion of the head, and the gliding of the
face and forehead from behind the pubes.

LABOUR, DIAGNOSIS AND MECHANISM 173

Moulding of the Head and Caput. — These changes are pretty much the
same as those found in normal face presentations. The caput will be found
over the eye and adjacent parts, on that side of the face which lies anterior
in the pelvis.

General Character of Labour. — The prognosis is not so good in these cases
as in vertex presentations. Labour is prolonged as already mentioned, and
manipulations are often necessary. In the unreduced mento-posterior cases
the mother runs all the risks of arrested labour.

There is danger to the foetus from over-extension of the neck, especially
when the chin is backwards ; and the cord may prolapse. (For " Manage-
ment," see p. 197.)

Bkow Presentations

The head in these cases, which are very rare, is in an attitude midway
between flexion and extension ; and the longest diameter, the mento-vertical
(5| inches), endeavours to engage in the brim. The head is in consequence
in a state of unstable equilibrium, and no doubt practically all face cases
pass through this condition at one time or another in their progress ; so
that until it engages in the brim, or at all events persists in endeavouring
to engage, this attitude has no special importance.

Engagement at all, in the case of a normally sized head and normal
pelvis, is impossible until a very great amount of moulding has taken
place.

Mode of Production. — When the head lies on the brim in this attitude
the downward pressure must have a vertical direction, or if there is a
tendency towards flexion or extension the obliquity of the uterus must be
exactly enough to counteract such tendency and preserve the unstable equi-
librium. Thus the cause of brow presentations is the same as that of face
presentations, but acting less completely.

On each side of brow presentations may be placed a series of presenta-
tions of the vertex and of the face. Nearest to it on the one side, that of
flexion, is the imperfectly flexed head that leads to persistence of the

occipito-posterior position, and nearest on the side of extension is the incom-
pletely extended face presentation which leads to persistent mento-posterior
mechanisms.

Diagnosis. — On abdominal examination, if the woman be a favourable
subject, the projection of the occiput and the chin can be made out, one on
each aspect of the child. The head will in practically all cases be lying
high, since it cannot enter the brim.

Per vaginam, if the head can be reached, the bregma is found at one end
of the presenting part and the glabella at the other. The orbital arches
will be recognised, and will indicate the anterior surface of the child.

Mechanism. — After the head has been reduced in its longest diameter
by moulding at the brim it descends, probably by slight advances of the
chin and occiput alternately, but the amount of advance in neither case

174

LABOUE, DIAGNOSIS AND MECHANISM

is enough to convert the presentation into a face or a vertex. Eotation
is controlled entirely by the shape of the pelvis, for the fit is a very tight
one indeed. So that whichever end of the head lies most to the front at
the beginning comes round under the pubic arch eventually. It is usually
the chin.

The forehead, now elevated into a marked projection, descends to the
vulva, and presents there. The head then flexes, rotating round some part
of the face, usually about the glabella, which lies under the pubic arch. The
vertex and occiput then glide over the perinseum, and the head is freed by
slight extension and the passage of the face and chin under the pubic
arch.

If the chin rotates backwards delivery in ordinary cases is impossible.

But if the head is very small and easily
moulded the chin will descend by ex-
tension and be born over the perinseum,
the vertex afterwards passing under the
pubic arch by flexion.

Even in the more favourable mechan-
ism the chances of delivery without
perforation of the head are extremely
small.

Eestitution will take place according
to the rules already laid down.

Moulding and Caput. — The head is
distorted to a remarkable degree. The
frontal bone is elevated, as already
mentioned, and the head slopes down
from this to the occiput very sharply.
The diameters lengthened are the
occipito-frontal and the suboccipito- frontal; those shortened are the
cervico-bregmatic and the mento-vertical.

General Character of Labour. — The mother runs great risks in these cases
from the prolonged labour and the necessary manipulations and use of
instruments. The perinaeuin is sure to be much lacerated.

The nervous centres of the child may be greatly damaged by the con-
siderable compression undergone by the head. (For " Management," see
p. 199.)

Fig

33. — Relations of head and pelvis in brow
mechanisms.

Podalic Lies

These lies include presentation of the full breech ; of the incomplete
breech ; of the knees, or a knee ; and of the feet, or a foot.

Full Breech. — This is the commonest presentation of the podalic end of
the child, because the natural attitude of the child in utero is that with the
thighs and knees flexed. This attitude makes the presentation consist of
the buttocks and the feet, the legs being crossed and closely applied to the
front of the body.

Incomplete Breech (sikge de'completS, mode des f esses, of French authors).
— The legs are extended on the thighs, so that the feet lie by the side of
the child's head. It is pretty certain that this attitude is the one, in many
cases, which has prevailed during pregnancy, for after the delivery of such
children the limbs frequently fly back to the same place, even when they
have been brought down into their natural attitude. In other instances
the legs after delivery will remain as they are placed, and the extraordinary

LABOUE, DIAGNOSIS AND MECHANISM 175

attitude must have been produced during labour by the hitching of the
heels at the brim.

Knee presentations are very rare, and are probably produced by manipula-
tions in most cases.

Footling presentations may be of one or of both feet. If only one
present, the half breech (one buttock, and possibly one foot) remains to
dilate the maternal passages. But if both feet come down the passages
are very imperfectly dilated before the head, and this is a matter of great
importance. The half breech attitude is, in all cases of podalic version, the
one intentionally produced.

Causes of the Podalic Lie. — The proportion in which it occurs is about 1
in 40 of all cases. It is due to the absence or to the inversion of the causes
which bring about the cephalic He in such a very large proportion of labours.

It occurs thus in cases of hydrocephalus, where the head-end of the
child is larger than the breech, and is better accommodated in the fundal
end of the uterus, and in cases where for some cause the specific gravity of the
child is not decidedly near the anterior end of the child, as in premature
children. In these last, too, the size of the child is not sufficient to make
its he in the uterus a matter of importance, and it is able to occupy either
end of the uterus by its head indifferently. It occurs where there is excess
of liquor amnii, or where the uterine walls are unduly lax, as they are
sometimes in multiparas. Twin pregnancy causes the adaptation of the foetuses
to the cavity of the uterus to be different from that present in single cases.
Contracted pelves prevent the head from resting on the cup formed by the
normal brim, and thus cause it to be more readily displaced ; and in these
cases the whole uterus lies higher than usual in the abdomen, and it and its
contents are more readily displaced. A placenta prmvia fills up the brim
and renders the seat of the head less secure.

The presentations of the foot and knee are brought about by a want of
close fitting between the breech and the brim, whereby a part of the presenta-
tion is allowed to prolapse in front of the rest.

Positions. — The positions are named according to the direction in which
the sacrum looks. They correspond therefore to the positions of the
vertex.

The diameter, however, which governs the rotations of the pelvis of the
child in the parturient canal is the bitrochanteric, which is at right angles
to the sacro-pubic, and may be in either oblique diameter of the pelvis, with
the sacrum facing either backwards or forwards. The positions with the
sacrum forwards are commoner than sacro- posterior ones, owing to the
lumbar convexity of the mother fitting more easily into the ventral concavity
of the child.

Diagnosis and Mechanism

i First Breech. — Left sacro-anterior.

The bitrochanteric diameter lies in the left oblique diameter.

Diagnosis. — On abdominal examination the back of the child is found
to lie on the left side of the uterus, and to be continued upwards into the
easily recognised head which occupies the fundus. The foetal heart is heard
to the left of the navel, a little above it.

Per vaginam the cleft between the buttocks lies in the right oblique
diameter.' Usually about the middle of the furrow the anus may be made
out, and in front and to the left of this the coccyx and sacrum with the
sacral spines, near the foramen ovale. It is not easy to distinguish the sex
of the child by its genital organs at this stage.

176 LABOUE, DIAGNOSIS AND MECHANISM

Mechanism. — The breech descends with a rotation of the anterior tro-
chanter, the left, to the front, obeying the shape of the pelvis and of the gutter
of the pelvic floor. The left trochanter appears at the vulva, and the right
trochanter forms the outer extremity of the curve produced by the pelvis
revolving round the left trochanter as a centre. This revolution is the same
as that of the head round the suboccipital region in vertex mechanisms.

The revolution causes a lateral flexion of the trunk, for the shoulders
lie pretty well in the plane of the brim. Eotation is combined with slight
extension of the trunk, for the child does not rotate so completely as to
bring its bitrochanteric diameter into the exact antero-posterior diameter of
the outlet. This again is quite comparable to the slight lateriflexion of the
head found in vertex cases at this stage (p. 163). Both buttocks are born
together.

An external rotation takes place immediately the hips are free, for the
shoulders are now lying in an oblique diameter, and the trunk has acquired
a twist. The hips in consequence rotate a little way back so as to occupy
their former position, the sacrum looking slightly forwards. As the shoulders
now come down they rotate into the antero-posterior diameter of the pelvis ;
the left shoulder forms the centre of a revolution in which the right sweeps
down the posterior wall of the canal, and both shoulders are born together.

The head comes into the pelvis somewhat flexed. The occipito-frontal
diameter lies in the left oblique with the occiput forwards. The occiput,
as the head descends, rotates to the front, obeying the shape of the outlet.
The longest diameter, the mento- vertical, remains as far as it is allowed by
the connection of the head with the neck, in the axis of the canal, and it is
on this coincidence of axes that the proper delivery of the head greatly
depends.

The nape of the neck is now lying against the lower edge of the pubic
arch, and the whole head revolves round this point, the chin soon appear-
ing at the vulva. The vertex is the last part of the head to be
born.

The delivery of the head is the critical part of breech presentation, for
not only is the progress at this stage slow, owing to the fact that the uterus
has contracted down to its smallest useful size, and thus leaves the expulsion
to be completed by the vaginal and abdominal muscles, but the child is in
a precarious condition. For the placental area is contracted, and the blood-
supply to the placenta is much diminished ; the cord is suffering pressure
between the head and the pelvic wall ; and the body-surface of the child is
very liable to be so stimulated by the cold air in which it now finds itself
as to bring about an inspiratory effort by reflex action, and to possibly fill
the lungs of the child with liquor amnii, meconium, and blood contained in
the vagina. The methods of assisting the delivery of the after-coming head
will be. considered elsewhere.

As the head rotates into the antero-posterior diameter of the outlet it
brings the trunk round in the same direction, and causes it to face towards
the mother's back, the left thigh and shoulder lying close to the mother's
right thigh.

Second Breech. — Plight sacro-anterior.

The bitrochanteric diameter lies in the right oblique.

Diagnosis. — Per abdomen. — The back is to the right, and the limbs to the
left. The head is felt at the fundus. The foetal heart is heard to the right
of and above the navel.

Per vaginam, the sacrum is found near the right foramen ovale, and the
cleft between the buttocks runs in the left oblique diameter.

LABOUlt, DIAGNOSIS AND MECHANISM 177

If left and right are interchanged, the Mechanism of this position is
described in the same way as that of the first breech.

Third Breech. — Right sacro-posterior.

Diagnosis. — The bitrochanteric diameter lies in the left oblique. The
back looks to the right and rather backwards, and the limbs to the left and
slightly forwards. The heart may not be heard ; if it is, it will be found on
the right side above the level of the navel.

Mechanism. — As the breech descends the right hip rotates towards the
pubic arch. The trunk is laterifiexed, and also bent slightly forwards. The
hips are then born in the same way as in the mechanisms just described,
and the abdomen of the child is turned to the mother's left thigh.

After this there are two ways in which the rest of the child may
follow : —

1. The trunk may continue to rotate in the same direction as that in
which it has already moved, and the shoulders will then descend in the
right oblique, the right shoulder still being in front. The occiput is thus
brought forwards and the rest of the mechanism is that of a second breech.

2. The shoulders descend in the same oblique diameter as the hips, and
the head will then lie in the right oblique with the occiput slightly backwards.

The head then comes down and the occiput is rotated forwards. This is
mainly on account of the tension in the direction of flexion which the
upper part of the child is now experiencing. If further descent were to
take place with the occiput backwards, the chin would have to be still
further flexed on the thorax to allow the neck and upper part of the chest
to follow the curve forwards of the maternal canal at this level, whereas if
the occiput comes forwards the tension is at once relieved, and the head by
an easy extension is born as in the preceding mechanisms. Also, if the head
came down with the occiput not forwards a long diameter of the head would
be thrown transversely across the outlet, one in fact near the mento-vertical, or
at least the mento-occipital, and this would cause the walls of the canal to
be stretched in a way that would bring about a rotation of the head into
another position, this position being one with the occiput forwards (see p. 162).

In the first kind of mechanism the rotation forwards of the back
of the child occurs between the passage of the hips through the brim,
and that of the shoulders through the same ring ; and in the second after
the passage of the shoulders.

Fourth Breech. — Left sacro-posterior.

The bitrochanteric diameter is in the right oblique, and substituting
left for right throughout, the mechanism is the same as that occurring in
the last-described position.

Abnormal Mechanisms in the Sacro-Posterior Positions. — These varia-
tions occur when the head descends into the pelvis with the occiput back-
wards and the head insufficiently flexed. Then, just as in presentations of
the head-end of the child, the longer diameters of the head lie across the
pelvis, and prevent the rotation forwards which normally takes place. The
occiput is found, therefore, in the hollow of the sacrum, unable to rotate
forwards as it has done in the hitherto described sacro-posterior positions.

The usual thing to happen now is that the occiput shall hitch on the
edge of the perinseum, which fits into the nape of the neck. The head then
flexes farther on to the chest ; and the chin and the rest of the face glide
under the pubic arch.

A less common way of delivery of the head in such a case is for the chin
to hitch behind the symphysis, and for the head to revolve round this as a
centre. The longest (mento-vertical) diameter of the head is thus thrown
VOL. vi 12

178 LABOUE, DIAGNOSIS AND MECHANISM

across the outlet, and the head is delivered as an inverted face, plus the
length of the chin.

Footling Presentations. — The Diagnosis of this presentation can be made
from the vagina only. One or both feet may present, and one or two limbs
may be found in the vagina. The only other presentation with which a
foot can be confused is that of the hand and arm. The characteristic part
of the foot is the heel, to which no counterpart exists in the hand. The
toes all lie close together, and there is no thumb to be separated from the
rest of the digits. The heel is distinguished from the olecranon, with which
it might be momentarily confounded, by tracing the sole of the foot
forwards and finding the toes. The direction of the heel shows the direction
of the occiput.

Mechanism. — If both feet are down, labour is easier in its early stages than
in the case of a breech. But when the shoulders, and later the head, come
down, these parts have to do the dilatation which should have been per-
formed by the breech, and there is corresponding delay. Otherwise the
mechanism is that of a breech. If, however, only one foot present, the
other being doubled up in its normal position, the state of affairs is much
more favourable. The half breech is able to dilate the passage pretty well,
and this presentation is the one always artificially produced after version.

It is important to remember how the mechanism is modified by the
presentation of one foot. This foot is the lowest part of the child, and is
therefore first influenced by the trend forwards of the pelvic floor. It is
in consequence rotated to the front wherever it may be to start with. The
bearing of this is that when version happens to be required in a pelvis of
which one side is more roomy than the other, and in which it is desirable
to make the occiput pass through the larger half, the operator has it in his
hands to place the occiput in which side he prefers. For instance, if the
right side of the pelvis is the larger, he will bring down the right leg of
the child, which, coming to the front, causes the occiput to come down into
the right side of the brim.

Knee Presentations. — The knee is recognised by its size and by the
movable patella. It is liable to be confused with the shoulder only, and
an abdominal examination will prevent this mistake being made.

Moulding of the Head in the Podalic Lies. — The head passes through
the pelvis flexed, that is, as has been already explained, with its longest
diameter as nearly as possible in coincidence with the axis of the parturient
canal. In consequence the diameters shortened are almost the same as
those in vertex presentations with the occiput forwards. There is the
difference, however, that the vault of the skull is not pressed in as it is in
the head-first cases, where it has to overcome the resistance of the pelvic floor,
and so the suboccipito-frontal and suboccipito-bregmatic diameters are not
so much reduced. There is also perhaps slightly less complete flexion in
breech cases. The fronto-occipital diameter is shortened considerably, and
the head is thus rendered slightly dome-shaped. If the child is born alive,,
however, there can be but little moulding. For the head is not long in the
pelvis, and remains for a still shorter time on the perinseum.

General Character of Labour. — The mother's safety is not endangered in
these cases unless manipulations are necessary. The child, however, is in
some danger if delivery of the head does not take place speedily after the
trunk is born. For the placental site is contracted, and the supply of
oxygenated blood to the child cut off; there is much risk of compression of
the cord between the head and the mother's pelvis ; and the stimulus of
cold air on the surface of the child's trunk is very liable to cause inspiratory

LABOUE, DIAGNOSIS AND MECHANISM 179

efforts while the mouth and nose are lying in the vagina, and mucus, liquor
amnii, and blood will in that case be sucked into the lungs.

In unreduced sacro-posterior positions the delay and the risk are greater.

The child's sterno-mastoid muscle is occasionally torn, and a haematoma
produced. This is sometimes followed by wry-neck. (For " Management,"
see p. 199.)

Transverse Lies

In the case of a transverse he the long axis of the child is at nearly right
angles with that of its mother. In practically all examples of this
abnormal lie the shoulder is the presenting part, and the head lies at a
considerably lower level than the breech.

Causation. — A. transverse lie has been shown, in discussing the mode of
production of the normal lies, to be, under ordinary circumstances, a con-
dition of unstable equilibrium for the child ; and there must, therefore, be
either a cause continually in action to keep the foetus in this relation to the
lonff axis of the mother's uterus, or an absence of most or all of those forces
which tend to place the child in the axis of the uterus.

Such conditions are found to be —

Contracted pelvis. — This cause acts through the increased uterine
obliquity usual in contracted pelvis, and by the head being prevented from
entering the brim.

Prematurity. — There is disproportion between the child and the uterus,
and the lie is indifferent (see p. 158).

Death (with possibly decomposition) of the foetus. — There is no muscular
tone, and the compact ovoid shape of the foetus in utero is not preserved.

Twin pregnancy. — The shape of the combined ovoid is irregular.

Placenta prsevia. — The lower uterine segment is filled up and the long
diameter of the uterus shortened.

Hydramnios. — The same reason holds here as in prematurity.

Tumours in the pelvis, or fibroids in the uterine wall, may displace one
of the poles of the foetus.

Positions. — The child may have its back anterior or posterior ; and in
either case its head may be to the right or left.

Owing to the dextro-rotation of the uterus the child will not lie in the
transverse diameter of the brim, but rather parallel to one of the oblique
diameters. The back is most commonly directed forwards for the same
reason as in all lies ; and owing to the dextro-rotation of the uterus the
head is usually in the left iliac fossa, since this is the lowest part of the
uterine cavity.

Diagnosis. — In all cases where there is no tumour complicating the
case the diagnosis can be made by the abdomen. The shape of the uterus
is characteristically altered, for its long diameter is transverse instead of
vertical.

The head is felt in one iliac fossa. The breech is higher than the head
and is about half-way up to the fundus. The lie of the child can usually
be quite well made out whether the uterus is contracted or relaxed.

Per vaginam there will early in labour probably be no presenting part
to be made out. Later on the arm frequently prolapses, and in any case the
shoulder may be reached when it has been forced down on the brim. If
there is any doubt at first, after an abdominal examination has been made,
an anaesthetic should be given, and the pelvis and abdomen thoroughly
explored.

If the membranes are unruptured when the examination is made, the

180 LABOUE, DIAGNOSIS AND MECHANISM

characteristic finger-like shape of the bag will be recognised. Care must be
taken not to rupture thern during an examination.

If the shoulder is felt it has to be distinguished from a knee, from the
breech, and from the side of the face. Its characteristic points are the
clavicle, acromion process, and spine of the scapula. If the examining
finger is able to pass the point of the shoulder and to reach the ribs in the
axilla, there can no longer be any doubt.

If the elbow is at the os it might be confused with the heel owing to
the projection of the olecranon. The finger should be passed along the
surface continuous with the projection, and the absence or presence of the
sole of the foot ending in the toes will serve to identify the part. But
such confusion cannot possibly arise if a careful abdominal examination
has been made. The direction of the head and of the back of the child can
be ascertained by abdominal and by combined examination. The axilla
felt per vaginam shows which way the head lies, and the spine of the
scapula shows the back. If the arm has come down, the thumb after
supination of the hand will point to the head, and the palm will show
which is the ventral surface of the child. If the prolapsed hand is the
right one the right hand of the physician will be able to grasp it as in
shaking hands, whereas if it is the left this cannot be done.

Natural Course of Labour if unassisted. — The prognosis is very un-
favourable in these cases, both for the mother and the child. Speaking
generally, the usual course of things is the os dilates very slowly, owing to
the projection of the bag of membranes. This projection in the form of the
finger of a glove already mentioned is due to the fact that there is no ball-
valve in this case, such as is provided by the head in normal cephalic lies, to
prevent the whole intra-uterine pressure coming on the bag of membranes.
The membranes are therefore thrust forward unduly, and they rupture long
before they have done their work.

The cord often presents, and when the membranes rupture, prolapses,
for the presenting part does not fit the lower uterine segment, and the
cord slips past. This is made more easy by the child's belly being close
to the os.

When the membranes have ruptured, the liquor amnii drains rapidly
away, and the uterus retracts on the foetus. The foetus is driven down
into the lower uterine segment, which soon thins owing to the tension
caused by the retracting upper segment and to the transverse stretching
caused by the bulk of the child. The uterus may now become tetanic, and
the woman may die in that way soon from exhaustion. Or the uterus may
become exhausted, and then on a renewal of its efforts may become tetanic.

Rupture of the vagina or lower uterine segment may occur.

Spontaneous delivery of one of the kinds to be mentioned may take
place.

In all these cases the child soon dies after the membranes have ruptured
owing to the retraction of the uterus. This arrests the placental circulation
by pressure, and in the same way kills the nerve-centres. (For " Manage-
ment," see p. 204.)

Spontaneous Deliveky

This is possible only when the child is dead or small.

If it is alive, and possesses its muscular tone, delivery may happen by
(1) spontaneous rectification; (2) spontaneous version; or very rarely by
(3) spontaneous evolution.

LABOUR, DIAGNOSIS AND MECHANISM 181

If it is dead it may be delivered by (1) spontaneous evolution, or by
(2) spontaneous expulsion (corpore conduplicato).

Spontaneous Rectification. — This occurs above the brim and with
unruptured membranes. By this movement the lie is converted into a
cephalic one. It is brought about by the tendency of the uterus to resume
its normal shape during contraction. The projecting head and breech are
pushed in towards the middle line, and the child is caused to lie in the axis
of the uterus. This movement would be represented artificially by cephalic
version.

Spontaneous Version. — This is a poclalic version of the child taking
place spontaneously. As the uterus contracts the breech is forced down,
and the trunk of the child is pushed across the brim in the direction of the
head. This must take place soon after the membranes have ruptured and
when not too much liquor amnii has escaped. Then, even if the arm has
prolapsed, which it often does, the elastic spinal column is able to transmit
the pressure in such a way that at the cephalic end of it the direction of the
force is converted into an upward one, the lowest point of the curve of the
spine dipping a little way into the brim. The head rises and the breech is
forced into the brim. The shoulder rises out of the brim, and the lower
part of the trunk turns into the hollow of the sacrum, thus bringing the
head to the front well above the symphysis. The curve of the foetal spine,
which had its convexity downwards to start with, comes now, on account of
the descent of its caudal end, into the pelvis, to have its convexity upwards.
The lower end of the child being in the axis of the cavity, the head is able
to be pushed by the inward pressure of the uterine walls into the middle
line, and the case is thus converted in an ordinary podalic lie.

The important feature of this mechanism is that the descent of the
caudal end of the foetus into the pelvic cavity takes place with the
shoulders above the brim. This will be appreciated when the next
paragraph is read.

Spontaneous Evolution. — The events in this method of delivery occur
below the brim. The child is practically always dead or very premature,
though delivery of a child at term by this movement has been recorded.

The difference in mechanism between this and the last described case
begins when the child lies with its shoulder in the brim. The spinal
column, being devoid of tone, does not form an elastic rod as in spontaneous
version ; so that when the uterus forces the breech down the shoulder is
thrust deeper into the pelvis, and does not glide across the brim. The
shoulder is driven down into the pelvic cavity. This is followed by the
side of the thorax, the abdomen, and finally the breech, which finds itself
in the hollow of the sacrum. The side of the neck is now jammed against
the back of the symphysis, and the shoulder comes down under the pubic
arch and presents at the valve. The thorax and then the breech are forced
down past the head and neck and are born, the legs being the first part to
make a complete escape from the canal. The rest of the trunk and the
head then follow as in a breech case.

Spontaneous Expulsion (corpore conduplicato).- — The child here is always
dead and small. The body is born doubled up, flexion taking place about
the lower dorsal region, which is born first. The chest is squeezed against
the belly, and the head and pelvis are born together last.

182

LABOUE; MANAGEMENT OF

Management of Labour

Preparation for

Antiseptic in .

Anaesthetics . ...

Management of 1st Stage
„ „ 2nd Stage

„ „ 3rd Stage

after Delivery

182
183
186
188
189
192
195

Management of Special

Pre-

SENTATIONS

196

Occipito-Posterior

196

Face .

197

Brow .

199

Breech

199

Transverse .

204

In the general management of labour there are three essential important
indications : —

1. To prevent any septic infection from being introduced from without.

2. Be ready to assist when necessary during labour, and thus recognise
early and possible dangers. Assistance may be required to prevent undue
length of labour from any cause, retention of any parts of the placenta or
membranes, also help will be required to arrest haemorrhage, to avoid lacera-
tions to the genital tract or accidents to the child.

3. Eeduce suffering to a minimum by the administration of an an-
sesthetic.

Preparations for Labour. — If, as is usually the case, the doctor has
seen the patient at least once before labour commences, special instruction
should be given as to the management of the last fortnight of pregnancy, in
regard to the care of the nipples, the systematic clearing out of the rectum,
and the use of hot baths ; vaginal douching, if any reason to believe that
there is a venereal discharge (see " Pregnancy, Management of "). In most
cases it is necessary to give the patient a list of the appliances that must be in
the house, and to advise as to the choice of the room and position of the bed.

Choice of a Boom. — The room in which the labour is to take place should
preferably be large and airy, with a south or western exposure if possible. A
patient always gets on better if the room is bright, and gets a certain amount
of sunshine. There should be an open fire-place (not a gas stove), and a good
window to ensure proper ventilation. A fixed basin in the room is never to
be commended, as there is always the possible danger of sewer-gas entering by
it. If the room can have a dressing-room opening off it so much the better,
as the bathing of the child, and the nurse's preparation of food, douches, etc.,
can be carried on without disturbing the mother. It is also better for the
nurse to sleep in the second room at night. The temperature of the room
should be kept at 60° to 65° F.

The led should be fairly hard, so as not to form a pit where the patient
lies. A feather bed is out of the question. A narrow bed, standing out
into the middle of the room, is the most convenient during labour, as the
patient can be more easily got at, and the administration of the anaesthetic
is easier. If the bed is not narrow, and cannot be placed so that there is
access to both sides, it must be arranged so that the doctor has access to the
patient's right side : if this is not done the examination of the patient when
on her left side has to be made with the doctor's left hand, or otherwise
entails a great deal of moving. The bed is made up in the ordinary way,
then covered with a mackintosh sheet, well tucked over the edge, and
covered with a draw-sheet. It is of great advantage to have over this a
thick square of absorbent wool, which is burned after it is soiled by dis-
charges. This should be changed once or twice during labour.

LABOUK, MANAGEMENT OF 183

List of Special Articles required

Douche can, 2 quart size.

< J lass vaginal nozzle.

Higginson's enema syringe.

Gum-elastic catheter or rubber catheter, size 8.

Bed-slipper.

Mackintosh sheet (size 1 yd. sq. at least).

4 absorbent wood wool sheets : 2 large size, 32 in. by 32 ; 2 medium size, 26 in.

by 20.
2 dozen large-sized wood wool towellettes. These are better in every way than

ordinary linen diapers. .

4 binders of strong towelling (linen or huckaback), 1 yd. wide by lj yds. long. The

binder is folded lengthways.
Box of assorted safety-pins, some specially large for the binder.
Small bottle of best olive oil. (For removing vernix from the child.)
Creolin.

Chloroform, 4 oz.

Linen thread, 1 hank, boiled and put into a bottle.
Some pieces of fine clean linen. A pair of scissors (blunt-pointed).
A dusting powder of equal parts of boracic acid, prepared chalk, and starch ; this

can be scented with rose or violet.
Boracic acid solution.
Brandy or whisky.
A new nail-brush.
A packet of absorbent wool.
Fluid extract of ergot, 4 oz.
Castor oil, 3 oz.
Complete set of clothing for child (see " New-Born Child ")■

The medical man should attend as soon as possible on being summoned.
Not only is it a great mental relief to the patient, but it also is an oppor-
tunity to diagnose the sort of labour that is likely to take place. If the
presentation is abnormal, it allows of a chance of rectifying it by postural
treatment during an early stage.

The practitioner should take with him . —

A lubricant for the fingers ; a tube of 1 in 1000 corrosive sublimate and glycerine is

useful, it does not'get infected as a pot of vaseline would.
Tabloids of corrosive sublimate.
A pair of forceps.
Needle-holder, pair of scissors.
Needles, and strong silk or catgut.
Hypodermic needle, with hypodermic tabloids of ergot, morphia, strychnine, and

digitalis.

Asepsis and Antiseptic Measures

It is not too much to affirm that the most essential point in the
successful management of a midwifery practice is a thorough knowledge
of the theory and practice of asepsis. The extraordinary reduction in the
mortality shown by the records from the various lying-in institutions since
the adoption of antiseptic methods, proves that if the principles of aseptic mid-
wifery could be perfectly carried out there would be no deaths from septicaemia,
and that there would be also a great reduction in the diseases directly due
to childbirth. With regard to this point some interesting figures are given
by Dakin from a study of a large series of hospital statistics ; he shows that
the unavoidable deaths from child -bed which are caused by diseases
other than septicgemia may be taken as about -2 per cent, which
figure represents the present ideal death-rate. With care, equally good
results can be obtained even under apparently adverse circumstances. _ Thus,
out of a series of 1549 consecutive cases under the writer's care in out-

184 LABOUK, MANAGEMENT OF

patient dispensary practice, the total mortality was 4, or 1 in 397, or "2 per
cent ; the causes of death were rupture of the uterus, pulmonary embolism
(2), and pneumothorax (phthisis pulmonalis). These results were simply
due to strict cleanliness in all the details of the confinement.

Before studying in detail the methods of preventing infection from the
hands and clothes of the doctor or nurse, and from dirty instruments, etc., a
brief reference may be made to nature's method of keeping the vagina sterile.

Kronig has shown that the normal vaginal secretion in pregnant women
has a germicidal reaction. It contains non-pathogenic bacteria. The vagina
has been found to be aseptic within forty-eight hours after the introduc-
tion of septic bacteria. This bactericidal power is not apparent, it is not
due to a simple process, but it is quite possibly the result of a joint chemical,
mechanical, bacterial, and leucocytic action. In addition to the germi-
cidal action of the vaginal discharge, the operculum or plug of mucus block-
ing the cervix completely prevents the entrance of bacteria into the uterus.
When the membranes rupture, the liquor amnii washes out the greater part
of the vagina and carries off the bacteria present. After the birth of the
child, when the walls have been stretched to their utmost, the liquor amnii
that comes after the child is able to wash out any remaining bacteria. In
this way the uterus is kept free by nature from bacteria after delivery.

As in the course of labour vaginal examination and operations must be
performed, it is necessary to do all that is possible to avoid the introduction
of germs. The keynote to this is absolute cleanliness in every detail.

In arranging the method to be adopted it is well to have the details as
simple as possible, so that they can be constantly carried out. It must also
be remembered that many antiseptics are incompatible when mixed together.

Soap decomposes corrosive sublimate, iodine, and permanganate of potash ;
carbolic acid and permanganate of potash are incompatible. Carbolic acid
and soap can be used together.

Cleansing of the Hands. — The thorough cleanliness of the hands is as
important for the nurse as for the doctor, and neither should touch the
genitals of the patient without having washed the hands in some such way
as the following : — First, scrub the hands, and especially the nails, thoroughly
with soap and hot water ; the variety of soap is not of importance provided
there is a good lather ; then rinse the hands in plain hot water to remove
all the soap, and thereafter soak them in a 1 in 500 solution of corrosive
sublimate for one minute. Never place the hands direct from the soapy
water into the antiseptic, as soap decomposes corrosive sublimate. It is not
necessary to use a lubricant for the examining finger, but if it is preferred
avoid the use of oily or fatty materials, as it is almost impossible to render
them aseptic. Pots or boxes of so-called antiseptic vaseline give a false
sense of security. They are usually far from being aseptic, having been
contaminated by discharge and blood-stained fingers.

A collapsible tube of carbolic acid (1 in 40) and glycerine, or a 1 in 500
mixture of corrosive sublimate and glycerine, are perfectly safe. The benefit
of having the lubricant in the tube lies in the fact that it cannot get soiled
by dirty fingers. Carbolic acid is the more useful, as it can be used for
forceps ; if the sublimate is used the mercury is deposited on the instrument.

Cleansing of Appliances and Instruments. — Vaginal nozzles are best
made of glass, and should be boiled for at least five minutes before use.
The catheter to be used should be new. Before and after using, both these
instruments should be washed and kept in an antiseptic solution — 1 in 40
carbolic, or 1 in 1000 sublimate.

Mackintosh sheets must be washed over with carbolic before being put

LABOUE, MANAGEMENT OF 185

on to the bed, and bed-pans should be carefully washed and disinfected
before and after use.

All the instruments to be used should be of metal, so that they can stand
being boiled ; and this should be done for five minutes, and after boiling
they are immersed in an antiseptic solution.

Cleansing of the Patient. — This must be thoroughly carried out to ensure
that the douche or clean fingers of the doctor or nurse, or the nozzle of the
douche, will not get contaminated from bacteria round the external genitals,
and thus carry infection into the vagina. At the commencement of labour,
and before any examination is made, the nurse should thoroughly wash with
soap and water, and then rub over with a 1-40 carbolic lotion, or wash off
the soap, and then scrub with 1 in 1000 corrosive sublimate. This washing
of the external parts is most important, and must be repeated from time to
time if the labour is long, and is also necessary at least once daily during
the puerperium. An old sponge or loofah should not be used for this,
but rather a new piece of flannel, or a bit of absorbent wool or tow. If
flannel be used, it must be washed out and kept in solution until required ;
the wool and tow can be burnt.

If any operation is to be done which entails the hand or instruments
passing into the uterus, the vagina must be disinfected as well. This would
not be necessary if we could be certain that the vaginal discharge is normal,
but it so often is swarming with bacteria that are capable of becoming
pathogenic when introduced into the uterus. To do this douche the vagina
(see infra), then scrub it all round with the fingers and a small piece of
soap, and then repeat the douche.

Douching. — Kronig, when making experiments on the normal vaginal
secretion, found that after douching with plain water the germicidal action
was lessened, and after a corrosive sublimate douche the action was destroyed,
probably by precipitating the albumin. Thus it seems that both ante-
partum and post-partum douching, apart from being quite unnecessary as
routine work in a normal case, may actually do harm. Careful douching is,
however, indicated under the following conditions : —

Ante-partum. — 1. When there is an offensive ox purulent discharge from
the vagina, e.g. of venereal cancer, etc.

2. In cases where any operation or manipulation is to be performed in
the uterus.

3. If the liquor amnii has lain long in the vagina during a prolonged
labour it may begin to decompose, therefore douching is advisable.

Post-partum. — 1. Where any operation or manipulation has taken place
inside the os uteri during labour. This category includes cases where forceps
have been applied to a head above the brim, internal version, induction of
premature labour, removal of retained or adherent placenta or membranes.

2. In some cases where the membranes have ruptured early, and the
labour is unduly prolonged. Owing to the loss of liquor amnii during the
long period there will be none left to wash out the vagina after the child's
birth.

3. If th-Qfcetus has been putrid.

4. In all cases where there has been a 'purulent discharge either before
or during labour.

5. Any time during the puerperium if the lochia become foetid.

6. Cases of post-partum haemorrhage. Here, however, the object of the
douche is not so much its antiseptic or cleansing property as the promotion
of uterine contractions so as to arrest hemorrhage.

The Composition of the Douche. — Its antiseptic properties are only of

186 LABOUE, MANAGEMENT OF

use by keeping the water in the douche antiseptic. The antiseptic sub-
stance does not remain long enough in the vagina to destroy the bacteria.
The water used should be boiled, allowed to cool, and strained through
muslin. Corrosive sublimate is not of much use for douching purposes ; if
used before labour it renders the tissues rough and more rigid. After
delivery, if used too strong, or if any is left behind, it may cause symptoms
of mercurial poisoning (spongy gums, foul breath, diarrhoea, and abdominal
pain). The strength of this substance should be, if used, from 1 in 5000 to
1 in 8000 ; if stronger the symptoms of poisoning are very apt to appear.
Members of the phenol groups of substances are more satisfactory. Carbolic
acid 1 in 60, or creolin 1 teaspoonful to the quart of water. This latter is an
exceedingly safe and useful substance, and being non-poisonous can be used
always.

The douche should be given by means of a douche can rather than a
Higgenson's syringe, the advantage being that a constant stream can be
applied, and there is thus much less chance of introducing air. It can be
given in almost any position. There is further no chance of introducing
any pieces of debris and clot that are apt to get drawn into the tube, as is.
the case where a Higgenson's syringe is employed. The can should be
■capable of holding two quarts of solution. The nozzle is best made of glass,
with the perforations in the sides of the nozzle, and not one central one at
the top in case of injecting fluid into the uterus. This might quite easily
.occur immediately after labour when the os is patent.

To administer the douche, if a bed-pan is available, the patient must lie
on her back, and with the shoulders raised and the bed-slipper arranged
heneath her. If not she should lie in the left lateral position, with the hips
drawn well over to the edge of the bed ; this is less likely to soil the bedding.
For a cleansing douche the antiseptic solution should be at a temperature of
100° F. to 110° F. If required to check haemorrhage the temperature must
be from 115° F. to 120° F. When the patient complains of the heat a little
soap or carbolised glycerine smeared over the labia, perineum, and buttocks
•enables the patient to bear the heat better. ■ A small quantity of the fluid
should first be run off, so that the tube may contain no air when it is intro-
duced into the vagina. The nozzle is passed for 2 inches into the vagina,
and the tap turned on. The left hand of the nurse must be laid over the
uterus to prevent the fluid finding its way into the uterus, or from the
uterus into the tubes, and then out through the ostium abdominale. This is
very unlikely to happen with a vaginal douche and with a nozzle not hav-
ing a central perforation. Eetention of the fluid in the vagina is prevented
by pressing firmly down into the fundus in the axis of brim at the end of
the douche, and at the same time depressing the perineum by the nozzle.

Sanitary Condition of the House. — This should be ascertained to be free
from defective drainage ; any sewer gas finding its way into the lying-in
room from water-closets, fixed-in basin, ventilating pipes, is a source of ill-
ness and danger during the puerperium. It is, however, doubtful if sewer
gas is ever the actual cause of septicaemia, probably it is not.

Anaesthetics

Anaesthesia is as justifiable in all obstetric cases as it is in surgical
operations, and in the more difficult cases it is as indispensable. In a
normal labour it not only prevents the acute suffering which accompanies
the second stage of labour, but is frequently of actual assistance in the pro-
gress. If the anaesthesia is carried to a deeper degree than is required to

LABOUli, MANAGEMENT OF 187

alleviate the pain the spastic state of the uterine and cervical muscle
becomes relaxed, and the voluntary action of the abdominal and pelvic
muscle is abolished, thus enabling any operation, e.g. turning, to be carried
out much more easily than it otherwise could be. Probably the best
anaesthetic to use is chloroform. In spite of all that may be alleged against
its use it has the following advantages : chloroform is more manageable and
more rapid in its action, and also more agreeable than ether. Further, when
given in small quantities short of surgical anaesthesia, it exercises its effects
in some degree, and it does not require the undivided attention of a skilled
administrator.

If complete anaesthesia is necessary, ether can be used, as there will be
almost invariably a skilled assistant present who can devote his whole
attention to the anaesthetic.

The immunity from danger during anaesthesia possessed by parturient
women is well known and lasts until the birth of the child. A very few
cases of death have been recorded, all occurring when the patient has been
anaesthetised to the full surgical degree. The cause of the immunity is not
known ; one reason ascribed has been the physiological hypertrophy of the
heart which tends to prevent syncope ; another theory is that alterations in
the vaso-motor system of the pregnant woman enable her to resist the toxic
action of chloroform to a greater extent than usual.

The possibility of post-partum haemorrhage should be borne in mind ;
the general relaxation of uterine tissues produced is supposed to increase
the dangers of haemorrhage. Haemorrhage is very rare after the adminis-
tration of chloroform if sufficient attention be paid to the uterus during the
third stage of labour.

If a healthy woman in labour inhales a small quantity of chloroform she
quickly passes into a semi-comatose state, perception is diminished, and the
general sensibility is dulled, yet she is quite conscious when spoken to.
During the intervals between the pains she lies quietly asleep, but at the
commencement of a contraction she grows restless, groans, and if the os uteri
is fully dilated she bears down ; she appears to be conscious of the pains, but
does not suffer from them.

The anaesthesia has not much effect on the contractions, the frequency
at first is slightly diminished, but it soon regulates itself. Each individual
contraction becomes more energetic and effective than before on account of
the resistance from the rigidity of the canals being reduced.

An anaesthetic is of special value in nervous, excitable patients, who on
account of the fear of increasing their own sufferings almost entirely abolish
the assistance that is obtained from the voluntary efforts of the abdominal
muscles. When deep anaesthesia is necessary, as in cases of obstetric opera-
tion, an assistant is usually required in order to allow the physician to
devote his whole attention to the operation.

The Eules for the Administration of Chloroform. — The anaesthetic
should not be started until the end of the^rs^ stage of labour. Before this
there is little need for it on the ground of suffering, but in some cases of
rigid cervix it may be employed after simpler remedies have failed.

During the administration there should be perfect quietness in the
room. Chloroform may be given by the open method, or preferably by one
of the graduated methods, e.g. Krohne's apparatus, or one of its modifica-
tions, described vol. i. p. 184. If the graduated method is not available,
a few drops of chloroform are put on the end of a towel and should be
given only when a pain is coming on, and then is withdrawn as soon
as the pain is over. During the second stage the anaesthesia is most useful.

188 LABOUR, MANAGEMENT OF

The amount given is gradually increased as the head descends. This, by
alleviating the suffering to a great extent, enables the patient to bear down
more fully. As the head emerges at the vulva the patient should be fairly
deeply under. This allows the doctor to have more control of the move-
ments of the head, and thus there is less danger of a ruptured perineum.
After the birth of the child the anaesthesia should stop, but there is no
advantage gained by wakening the patient artificially. As the chloroform
is supposed to predispose to post-parbum haemorrhage the uterus must be
more carefully guarded than usual. It is unnecessary to give chloroform
in this stage even for the repair of slight tears of the perineum, as the parts
are usually insensitive from the stretching they have undergone. But if the
perineum is badly ruptured, or if the placenta is adherent, chloroform must
be given.

No harmful effect of chloroform upon the child has been established.
Occasionally there seems to be some slight delay in the establishment of
respiration in the new-born infant, but with slightly more vigorous stimula-
tion this is soon got over.

The Administration of an Anaesthetic under Special Conditions.
— In cases of heart disease the administration of an anaesthetic is necessary,
as the labour should in most cases be completed as soon as possible. The
slight tendency to post-partum haemorrhage is here rather an advantage than
otherwise, as it will relieve the extra burden thrown on to the heart when
the change in the circulation takes place after the birth of the placenta.

In cases of anaemia, ' after placenta praevia or accidental ante-partum
haemorrhage, it is better to give ether. If the labour is accompanied by
troublesome pulmonary complications chloroform is the best anaesthetic.

For the treatment of convulsions and chorea, and in the performance of
almost all major obstetric operations, the use of the anaesthetic is necessary.

Management of First Stage, or Stage of Dilatation

This stage begins with the commencement of true labour pains, and
ends with the complete dilatation of the os. Its duration is about fifteen
hours in primiparae and eleven hours in multiparae. The chief indications for
treatment are (1) to assist nature in every way ; (2) to maintain the strength
by means of suitable nourishment ; (3) to avoid needless examination.

Labour progresses most satisfactorily when the pains are regular. A
great deal can be done by keeping the patient quiet, interesting her, and
not allowing her to be disturbed or annoyed by the presence of undesirable
relatives.

The nurse's tact and consideration in this stage are most helpful. The
right sort of woman will try to interest and cheer the patient in every way.

The dress of the patient should be a clean nightgown, doubled up on a
level with the crest of the ilia, and pinned on the shoulders, and a petticoat
of some flannel material loosely tied round the waist.

An excellent and most convenient form of petticoat will be found in
taking three yards of flannel with a tape run into it lengthways. This is
tied round the waist, and the fulness taken to the back, and the ends pinned
together with safety-pins. This has the advantage of being most easily
raised up during the second and third stages of labour, and also it can be
very easily removed with the minimum of disturbance to the patient. The
patient also wears a larger size of woollen stocking and loose slippers. Also
during the first stage she should have on a dressing-gown.

One has at this stage constantly to keep in mind the factors that may

LABOUK, MANAGEMENT OF 189

interfere with the progress of labour. These are (1) the position of the
uterus not being that best suited for the ovum to dilate the os ; (2)
a loaded rectum; (3) an over-foiled Madder. At this time the patient
usually assumes an erect attitude, and either walks about or sits on a chair.
This should be encouraged, as the position helps the natural process of
dilatation of the os, owing to the influence of gravity and the force of
the pains driving the ovum downwards on the os. Voluntary " bearing
down " is of no use, as it does not increase the force acting on the os, and it
is further very exhausting. If the uterus be anteverted or obliquely in-
clined, the action of the pains presses the head on the brim of the pelvis
rather than against the os uteri, and thus a serious delay to labour is
caused. This can be rectified by applying a firm abdominal binder, and
letting the patient lie on her back until the head fixes in the brim. A
straight piece of strong linen towelling is much superior to any of the
varieties of shaped bands.

A loaded rectum may seriously interfere with the progress of labour by
offering an obstruction to the descent of the head. The method I have
found which ensures the rectum being in a satisfactory condition during
labour is for the patient to take for the last week of pregnancy a sufficient
dose of some mild purgative (e.g. liquorice powder) every night. Then, on the
onset of labour, if the bowels have been opened within five hours, do nothing
until the first stage has lasted about eight hours, then always clear out
thoroughly with a soap, water, and glycerine enema. If there is any reason
to doubt that the bowels have had the thorough preliminary clearing, give
an enema on the onset of labour, and another enema before the commence-
ment of the second stage.

The Madder very rarely requires the use of the catheter during the first
stage. But if necessary it must be used.

As this stage will probably last from eight to twelve hours, the second
indication, that of maintaining the general strength, may call for considera-
tion. At the beginning of labour there is no reason why she should not
have a full meal of plain food. After this the patient will not be at all
inclined for anything beyond some hot drink, a cup of warm milk, coffee,
tea, a cup of soup or thin gruel. The stimulating effect of the hot drink
acts often by increasing the strength of the pain. This, of course, can be
repeated at intervals. If the labour has been going on a very long time,
and the pains are growing feeble, the question of giving an opiate has to
be considered.

On first seeing a patient at the commencement of labour a thorough
careful abdominal examination should be made (as described under section
"Diagnosis," p. 152). This, however, requires to be supplemented by a
vaginal examination at the commencement of labour ; it is well to repeat the
examination after rupture of membranes, in case the rush of liquor amnii has
caused the prolapse of the cord or of an arm. Thorough antiseptic precaution
must be taken regarding the cleanliness of the external genital organs
and the operator's fingers, hand, and forearm. All instrumental and digital
interference, such as early application of forceps, digital dilatation of the
cervix, and unnecessary vaginal douching, are much to be deprecated.

Management of Second Stage

This, the stage of expulsion of the foetus, extends from the time of com-
plete dilatation of the cervix to the delivery of the child. Its duration is
variable. In primiparae it may last for three to four hours, while in

190 LABOUE, MANAGEMENT OF

multipara the average time is from one to two hours. It occasionally
occurs that the delivery is exceedingly rapid, and the child is born after a
very few pains. Such a rapid second stage is however not desirable, as it
predisposes to post-partum hemorrhage, and' is very apt to be accompanied
by laceration of the vagina and perineum. It may also be the cause of
imperfect involution of the uterus.

The chief phenomena are the regular and intermittent uterine contractions
aided by the voluntary contractions of the abdominal muscles. The sequence
of events is (1) the rupture of the membranes, brought about by the
removal of the support from the cervix ; (2) the gradual expulsion of the
child into the vagina ; (3) the pressure of the head on the perineum,
followed by its birth.

The lines of treatment are now as follows : — After complete dila-
tation of the os the membranes have served their function, and if they
have not ruptured spontaneously, it is best to do so artificially, as their
presence now retards the advance of the child's head. Artificial rupture
is best performed during a pain by scratching through the thin membranes
with the nail. If they are too tough for this the stilette of a catheter may
be used under the necessary antiseptic precautions. It is difficult to render
a hairpin aseptic, and therefore it should not be employed. After rupture
and the partial escape of the waters, the head, being no longer kept back
by the fluid, comes well down upon the cervix. The uterus, with the escape
of the liquor amnii, is able to contract and retract on to the body of the
foetus, and this acts as a stimulus to the pains which have now passed from
dilating pains to expulsive pains. There is frequently a short cessation
from pains immediately after the rupture, while the uterus is retracting on
the child.

During the early part of the second stage the patient should lie down,
she can assume any position that she cares to, except when an examination
is made, when she should lie on the left side with the hips down well to the
edge of the bed. Some arrangement must be made to help her in her
bearing- clown efforts. A board placed at the end of the bed against which
the patient can place her feet flat, and a roller towel fastened to the foot-
rail for her to pull upon will be found of great advantage. She should be
instructed that when the pain comes on to hold her breath, press with her
feet, and while pulling on the towel to " bear down " with all her strength.
By these means the pelvis and thorax are fixed, and thus the full action of
the diaphragm and abdominal muscles is obtained. Chloroform may now
be given just when a pain is commencing.

If the anterior lip of the cervix is pushed in front of the head it should
be pushed up during a pain as soon as it is diagnosed, as its presence is a
delay to labour, the bruised congested part may prove a ready starting-
place for a septic process during the puerperium.

The bladder must not be allowed to become over-distended, the pressure
of the head on the urethra often causes difficulty, and makes it necessary to use
the catheter ; a new gum-elastic catheter, or a flexible rubber one, size 10, will
be found more easy to introduce than a metal one. Guide the point of the
catheter by passing the index finger along the anterior vaginal wall until the
point of contact between the head and the symphysis is reached. The
pressure on these forms of catheter is rarely sufficient to obliterate the lumen.

Delivery of the Head and the Preservation of the Perineum. — As soon as
the head begins to distend the perineum more energetic treatment is called
for. With regard to the position of the patient there are two methods in
vogue, dorsal and left lateral. The lateral position is most usually adopted

LABOUR, MANAGEMENT OF 191

in this country ; it certainly has the advantage of allowing the operator to
see more clearly what is going on. If the patient lies on her left side, at
right angles to the edge of the bed, the hips coming well up to the edge of
the bed, and the legs flexed at the hip and running parallel with the side
of the bed, the best attitude for guarding the perineum will be obtained.

To preserve the perineum intact is very important, but if in spite of all
precautions a laceration occurs, it must be repaired at once. The methods
of doing this are described in the section " Injuries of the Generative
Organs," see p. 305. A certain class of cases is more apt to have a ruptured
perineum than others, e.g. elderly prirniparse, peculiarly inelastic perineums-
even in young prirniparse, a previously repaired perineum, or a specially
long perineum. Then certain malpresentations, as a persistent occipito-
posterior, are more likely to cause rupture. The administration of an
anaesthetic during this stage is often advisable, by giving tbe physician
more control over the movement of the head, and by lessening the
voluntary muscular power during the pains.

The methods adopted for the 'preservation of the perineum are modifica-
tions of the following principles, either to keep the head as much off the
perineum as possible by pushing it forward, or to apply direct support to the
perineum. The direct method is carried out by laying the palm of the left
hand on the perineum, with the concavity between the first finger and
thumb lying over the posterior end of the vulva, and then pressing the-
perineum upwards against the advancing head. The disadvantage of this-
method is that it prevents the serous exudation passing into the tissues of
the perineum, by compressing it between the hand of the operator and the-
child's head.

Of the various methods — indirect methods — which act by keeping the
head pushed as much forwards as possible, I have found a modification of
Kohl's method give the most satisfactory results.

This consists in applying support, not to the perineum, but to the-
presenting part. The two essentials to its success are, that the head
should remain flexed until the lowest possible point of the occiput comes to
lie under the symphysis ; after this point is reached extension may begin ;.
secondly, that delivery must take place between the pains, and not during
one. It is carried out as follows : —

The operator sits in such a way that when the thumb of the right hand
is applied to the presenting portion of the occiput, the elbow of the right
arm can rest on the operator's right thigh.

The thumb is applied to the most anterior part of the occiput, and the
index and middle fingers posteriorly upon that portion of the head lying,
nearest to the symphysis. Steady pressure is exerted during each pain
on the most anterior visible portion of the head, this preventing any strain
on the fourchette or perineum — at first during the intervals between the
pains, the right hand grasping the presenting part of the head, the chin is
made to flex as much as possible, while the forehead and face are pulled
forward in such a manner as to keep the chin at the same time in contact
with the chest. As soon as the lowest possible point of the occiput comes to-
lie under the symphysis the extension movement may begin.

As the pains get stronger the power required to keep the head back off
the edge of the perineum is considerable, and the right thumb has frequently
to be supported by the left hand. The patient at the same time should be
directed not to " bear down"; the voluntary efforts are prevented by making
her cry out, taking away the pulley. When the supra- orbital ridges pass-
the tense border of the vulva, the perineum retracts rapidly over the face-

192 LABOUK, MANAGEMENT OF

and the expulsion of the head is complete. This is the point when lacera-
tion is most apt to occur if it takes place during a pain, but if between the
pains the patient bears down and the doctor pushes the head forward it is
easily delivered.

The method adopted at the Eotunda Hospital is also a modification of
the indirect method. It is carried out by applying the hand behind the
anus and pushing the head forward.

Rectal expression is carried out by some; it consists in passing two
fingers into the rectum when the head is distending the perineum, hooking
the fingers under the chin of the child through the then recto- vaginal
septum, then by pressing forwards and upwards the head can be easily
delivered between the pains.

Local applications, such as hot fomentation or the application of vaseline
or other inunctions, are in use, but are not of much practical value. The
same may probably be said of digital dilatation of the perineum before the
descent of the foetal head. It is done by several times hooking a finger over
the perineum during a pain, and drawing it back towards the sacrum. If a
perineal tear seems inevitable the perineum may be slit laterally ; this small
operation is called episiotomy (see p. 305) ; it is doubtful if it is of much
service. It is claimed for the operation that it prevents deep lacerations
through the sphincter ani, and that by reason of the arrangement of the
muscular fibres the wounds heal spontaneously. However, as it is never
certain that a laceration is going to occur, and if it does take place, even
through the sphincter ani, the laceration heals well if stitched up at once ;
the special advantage of the operation is not very clear.

As soon as the head is born pass the finger round the child's neck to see
if there are any coils of cord round it. If one or more coils are found a
little more cord may be pulled down and the loop passed over the child's
head. If this is impossible owing to the cord being too tight the cord
must be divided and tied. The dangers of allowing the child to be born
with the cord round its neck are — (1) the child may be strangled by the
cord ; (2) the placenta may be detached by the tension on the cord ; and (3)
the delivery of the shoulders is delayed. While the cord is being set
free, the nurse should carefully wipe the child's eyes to remove any
discharge present. So as to give more room under the symphysis the right
knee may now be held up by the nurse, or a rolled-up pillow may be placed
between the thighs.

If the cord is pulsating the delivery of the child can be left to nature.
As the shoulders pass out through the perineum they must be watched to
prevent a laceration, and the operator should keep the left hand carefully on
the abdomen. If then there are any signs of the cord not pulsating the
child must be delivered at once. The best way is to press on the fundus, and
as the shoulders come down, in order to assist the posterior shoulder getting
over the perineum, lift the child up towards the mother's abdomen, then
depress the child slightly to bring the anterior shoulder out from under the
symphysis. After this the rest of the body readily follows as the larger
portion has come first.

Management of Third Stage

This stage, lasting from the delivery of the child until the birth of the
placenta, should receive most careful attention in every detail, as the health
of the patient during the puerperium and afterwards depends mainly on
its successful management.

LABOUR, MANAGEMENT OE 193

The indication for treatment is to promote contraction of the uterus.
Eroni the moment of the birth of the child the uterus must be carefully
looked after, a light steady pressure being maintained by the attendant
keeping the fundus of the uterus in the hollow of the left hand. This
pressure must be continued for a short time after the birth of the placenta
and membranes. If the child requires any special attention from the
doctor, the nurse must maintain the pressure on the uterus.

Care of the Child. — The infant normally cries out as soon as it is born,
but if not, the mouth and fauces should be carefully freed from all mucus,
and some slight stimulation applied. A few smart slaps with the hands or
a dash of cold water are usually sufficient. If, however, the child is appar-
ently not going to begin breathing, the methods of artificial respiration to
be used in cases of asphyxia neonatorum must be adopted (see article
" Asphyxia," vol. i.). If the chloroform administration has lasted for a long
period there is a greater probability of the child requiring more attention in
this direction.

The question of late or immediate ligature of the umbilical cord was at
one time the subject of much discussion, but now it is generally considered
that the cord should not be tied until it has ceased to pulsate. Experi-
mental research shows that with late ligature of the cord the child gains a
considerable amount of blood. At the first inspiration the opening up of
the pulmonary circulation creates a negative pressure in the great vessels
near the heart, and thus the blood is sucked in from the placenta ; the
uterine retraction and contraction assists in compression of the placenta.
By these means the child receives about three ounces of blood (equivalent
to three pints in the adult). The children in whom the late ligation of the
cord is adopted are stronger and healthier than those whose cords are
ligatured at the moment of birth. There is insufficient evidence in favour
of the view advanced by a few writers that late tying of the cord is more
frequently followed by jaundice.

Method of tying. — The cord should be tied when it has ceased to pulsate.
The usual plan is to tie it in two places : first, about 2 inches from the
umbilicus, the second an inch or so nearer the placenta. This site for the
first ligature allows ample room for retying should the ligature slip. The
cord is divided between the ligatures. The second ligature is not necessary
if we wait until the pulsation in the cord has ceased. If there is a second
child in the uterus this second ligature is advisable, as possibly the vessels
of the two placentae communicate.

After the division of the cord the child is wrapped in some flannel
material and taken away by the nurse.

The phenomena of labour during the third stage are the occurrence of
intermittent contraction with permanent retraction of the muscular fibres.
This causes the placenta to be expelled from the uterus, while the bleeding
is stopped by the closure of the mouths of the vessels. Thus it is the
physician's duty to promote contraction of the uterus, in order to cause the
expulsion of placenta and any blood-clots, also to arrest haemorrhage and
prevent air getting into the uterus.

To promote Contraction of the Uterus. — As soon as the child is
separated the patient should be turned on to her back, and a small vessel,
such as a saucer or soap dish, placed under the vulva to catch any haemor-
rhage.

In order to have the uterus completely under control and to promote
contractions, the palm of the physician's left hand should be laid over the
fundus. With the ulnar border pressed downwards towards the promontory
vol. vi . 13

194 LABOUK, MANAGEMENT OF

of the sacrum and the thumb lying over the anterior surface, the whole body
of the uterus is thus within the grasp of the hand, and it is impossible
for the cavity to become distended with blood-clot during the intervals
between the contractions. A uniform pressure exerted over the fundus
is better than light touching on the surface, as this is apt to set up
irregular contractions. The uterus is found lying midway between the
symphysis and umbilicus.

The method of separation of the placenta and the diagnostic points
showing when it is in the vagina have been fully described (page 148).

The Eemoval of the Placenta. — The placenta may be got rid of in
various ways : —

1. Nature's unaided efforts.

2. Crede or Dublin method of delivery.

3. Eemoval of the placenta by hand.

4. Traction upon the cord.

Nature's unaided efforts are somewhat tedious. When the placenta has
been expelled into the vagina, which usually occurs within twenty minutes
of the birth of the child, it lies there, and is slowly extruded by the action of
the abdominal muscles. This process frequently takes several hours, and
for this reason the third stage is invariably shortened artificially.

Gride's or the Dublin method of delivery is certainly the best artificial
means we have of delivering the placenta. If practised as soon as the child
is born, that is, before the separation of the placenta, post-partum ha3mor-
rhage is very apt to occur as the mouths of the vessels will not have had time
to close. There is also some danger of portions of the placenta being left
behind. If we wait from fifteen to twenty minutes the placenta will
have had time to be extruded into the vagina, when expression is per-
fectly safe. The physician grasps the uterus firmly during one of its
contractions, and then first presses backwards and downwards, and then
changes the pressure to a forward movement, by which means the placenta is
expelled through the vulva. As the placenta appears it should be taken
hold off by the nurse and turned rapidly round and round to form the
membranes into a cord, thus diminishing the chance of their tearing. The
twist of membranes usually slip out at once ; if there is any difficulty, wait
until the uterus relaxes and they will slip out easily.

Removal of the Placenta by Hand. — If the placenta is still in the uterus
(retained) the methods of its removal are described (page 277). If it is
lying in the vagina there is no advantage to be gained over the method of
delivery by expression.

Traction on the cord is the worst of all methods of delivery. If the
placenta is not detached from the uterus before the traction is effected, the
central portion is pulled off the uterine wall, thus creating a vacuum into
which ■ the blood is poured from the sinuses, and if the traction is at all
excessive owing to the placenta being adherent, inversion of the uterus
may quite likely result. If the placenta is in the vagina, the method is
safe enough, but is more apt to cause retention of membranes than the
other methods.

Examination of Placenta and Membeanes. — The placenta on its
removal should be placed in a basin of water and submitted to a routine
examination. Firstly, the maternal surface. If the maternal side is
entire it will form a continuous surface when held upwards on the two
hands, but if a lobe or part of a lobe is left behind the surface will be
correspondingly irregular. The continuous edge of the amnion round the
placenta should next be examined in case it should be incomplete. If a

LABOUE, MANAGEMENT OF 195

pair of lacerated vessels are seen at the placental edge this denotes a
placenta succenturiata somewhere. If this is not found outside it must
still be in the uterus. Then inspect the membranes. The sac of the
amnion and chorion can be separated from one another without much
difficulty, and if split up completely it can easily be seen if the chorion is
attached all round to the placenta.

Should it appear that everything has not come away the uterus and
vagina must be explored by the hand. For method of procedure see p. 277.

The perineum should now be carefully examined for any tears, and if
there is any injury involving more than the fourchette it should be sewn
up at once (see p. 303).

Management after Delivery

For about half an hour after delivery the hand must be kept over the
fundus to prevent it becoming filled with clots. If the uterus become
flabby and lose its outline, the doctor must grasp and knead the uterus
firmly until a contraction is set up. This manipulation of the uterus,
besides preventing haemorrhage somewhat, relieves the severity of after
pains in multiparas.

Ergot may be given to further guard against any chance of haemorrhage.1
A few words here on the action and use of ergot are not out of place. The
physiological action of ergot is to cause tonic contraction of the entire
uterus. When given by the mouth it acts in fifteen to twenty minutes,
but in three to five minutes after a hypodermic injection. When given at
the proper time ergot is often of the greatest service, but if given too soon
its results are most dangerous.

The uterine contractions induced by ergot differ from the normal action
in being tonic in place of intermittent. Therefore it is only safe to give
ergot when the uterus is empty {i.e. after the birth of the placenta and
membranes), as then a state of tonic contraction cannot possibly do any
harm, and it is a good routine method to give a drachm of ergot to all
multiparas.

If ergot, however, is given during the first stage the tonic uterine con-
tractions kill the child and are even apt to loosen the placenta. It is only
permissible during the second stage if there is absolutely no danger of any
obstruction to labour being present. This can very rarely be made out
definitely.

During the third stage the tonic contractions of the uterus may cause
retention of the placenta. If this should be complicated with haemorrhage
the physican is in a very anxious position, as nothing can be done until the
placenta is removed.

As soon as it is apparent that the uterus is acting properly, attention
must be directed to making the patient clean and comfortable. All the
blood should be washed off the patient thoroughly. This is best done with
creolin and water, soap, and a piece of new flannel ; then the soiled cloth-
ing is slipped out from underneath the patient. No douching is required
unless there has been some form of interference during the second or third
stage. If it is indicated, see p. 185. Then the patient should be turned on

1 Schafer has shown that supra-renal extract is a'powerful stimulant of the muscle fibres
in blood-vessels, and more recently has demonstrated a similar action on the uterine muscle.
His observations suggest that this extract may be a very useful remedy in cases of post-
partum hemorrhage and other uterine conditions where stimulation of the uterine muscle is
indicated.

196 LABOUK, MANAGEMENT OE

to her left side again, and the knees drawn up in order to allow of a
thorough visual inspection of the perineum, in order to be certain if there
is any tear. Tears of the perineum and lacerations of the vagina should be
at once repaired (see " Labour, Injuries to the Genital Organs," p. 294).
Lacerations usually heal quickly and completely if sutured at once, and
special attention paid to the cleanliness of the parts. This consists in
washing the parts gently after micturition or defecation with a creolin
solution and the application of a dressing of dry iodoform gauze. The dress-
ing can be held in place by the diaper. If the wound fails to unite it is
probably due to syphilis or general lowered vitality.

The binder, although not absolutely essential, is a great comfort and
support to the woman, enabling her to turn on her side. The best form
of binder is a long strip of firm towelling, with no shaping. The
practice of placing a pad over the uterus usually results only in pushing
the uterus to one or other side, and does not serve any good purpose.
The binder is fixed by inserting the pins from below up, at about 1| inches
apart. The toilet is finished by applying a warm pad to the vulva.

After the patient is tidy a drink of niilk or beef tea may be given. As
a rule the patient can be left safely an hour after the birth of the child.

Directions should be left with the nurse to call the medical attendant
in the event of any hemorrhage, rigor, or syncopal attack occurring. This
will be further referred to under " Puerperium."

Management of unusual presentations of the child, viz., persistent
occipito-posterior, face, brow, breech, and transverse. In these sections it is
assumed that everything is normal except the position of the child. For
the etiology, mechanism, diagnosis, and prognosis of these special lies the
reader is referred to section on "Diagnosis and Mechanism," p. 151.

OCCIPITO-POSTEEIOR

If the occiput is posterior labour is likely to be prolonged, as the long
rotation of the occiput forward to the symphysis which takes place in the
majority of cases occupies some time. In a certain number, however, the
occiput rotates into the hollow of the sacrum, and becomes a persistent
occipito-posterior.

The management depends on whether the case is seen early or late.

1. Early, before Rupture of the Membranes. — If, on arriving at a case,
the position be diagnosed as a third or fourth vertex, the best treatment is to
turn the child round so that the back of the child lies to the front. This
is done as follows : — For the third vertex position — that is, the abdomen
looking forward and to the left, and the left shoulder anterior and to the
front — the operator places his hands thus — the left in front of the right
shoulder, and the right behind the left shoulder, by a series of gentle pushes
the child can easily be turned. If the rotation is fully effected the
occiput now lies anteriorly, and quickly begins to descend and press on the
os, and there is no chance of it slipping back.

2. Late, when the Head is engaged in the Pelvis. — As there is always
the possibility that the head may rotate naturally wait about three
hours. If, during this time, it is neither rotating nor advancing some
help must be rendered. This should be in the direction of imitating
nature as much as possible, and by increasing flexion in all cases where
it is not well marked. If we can flex the head the occiput will descend,
and then the head will rotate forward. Flexion is attempted by pushing
upwards and backwards on the frontal pole of the head during a pain. This

LABOUE, MANAGEMENT OF 197

is sometimes effectual, but if not soon followed by descent of the occiput it
will be of no use. An attempt can then be made to make the occiput
descend by use of the vectis which is passed over the occiput, and with it
is pulled downwards and forwards. The vectis is not much used, but the
single blade of a forceps, if it has an extra sharp curve at the top, can be
used, (For vectis see " Obstetric Operations.")

If the attempts to flex the head have failed, and the physician has not a
forceps with a suitable curve to act as a vectis, rotation of the head by the
hand can be tried, the attempt being made between the pains.

Pass the left hand into the vagina. Grasp the occiput and try and
bring it round to the front, at the same time try and move the shoulders
round. If the rotation of the shoulders is not complete the head will slip
back into its old position. This method is of special value if the accou-
cheur have small hands. It is a useful plan to rotate the head, hold it in its
new position, and then apply forceps. This requires much less effort in
traction than in trying to deliver a persistent occipito-position with forceps.
The danger of over-twisting the child's neck is more theoretical than real.

Forceps. — This is sometimes quite successful, as after the head has
descended by pulling it rotates naturally. When this takes place the
forceps must be taken off and reapplied. If, however, the occiput does not
turn, a great deal of force and time is often required for the tugging, and
when delivery is at last accomplished there is great danger of having a very
badly lacerated perineum.

Face Presentations

(For " Mechanism," see p. 168.)

When this presentation is diagnosed sufficiently early an effort should
be made to transform the face into a vertex presentation. This is only
possible under the following circumstances : —

1. When the face is not fixed in the brim. If it is fixed the move-
ment is impossible owing to the relationship of the diameters.

2. While the membranes are unruptured.

3. When the abdominal walls are lax.

4. When there is no cause present, such as a tumour of the neck, to
prevent the child's head flexing.

Before making any manipulative attempts of this kind an exact
diagnosis of the presentation and position must be made. There are
two methods that may be tried : first, by pressing on the face and occiput ;
secondly, Schatz method of pressing on the shoulders and breech. Both
manoeuvres are harmless and both may fail.

Manipulative Measures. — The first method described by Herman is to
place two fingers in the vagina, and the other hand on the abdomen over the
occiput. Then with the internal hand press the face upwards by pressure
on the jaws and then on the forehead ; while with the external hand push
the occiput down into the pelvis. When the forehead is raised above the
pelvic brim use both hands on the abdomen, the left hand still pressing the
occiput downwards, and the right hand pressing the face upwards and
forwards. The objection to this method is that it will probably rupture the
membranes.

Schatz Method. — This requires very lax abdominal and uterine walls, so
it is well to anaesthetise the patient fully.

With both hands raise the head up from the pelvis by pushing upwards

198

LABOUK, MANAGEMENT OF

the anterior shoulder and chest of the child through the abdominal wall ;
then with one hand on the chest push in the direction of the child's back,
while the other hand pushes the breech in the opposite direction ; lastly,
when the breech is directly above the pelvis push it downwards and apply
a tight binder. Occasionally the flexion is not complete, and the face is
transformed into a brow.

If the case is seen too late to transform it into a vertex, it must remain
a face and be treated as such. The patient's friends should be warned that
the labour in all probability will be long and tedious, and that the risk to
the child is greater than usual.

The chief cause of delay is that the face is a bad dilator, and for want of
proper support the membranes tend to rupture early. Therefore do every-
thing to prevent early rupture, viz., keep the patient in bed, prevent her
straining, and do not make an examination during a pain.

If the membranes rupture early and the face presses on to the os at each
pain, leave the case to nature ; also, if the os is fully dilated and the head

Fig. 34. — "Schatz's method" of converting face presentations into vertex presentations.

is in the pelvic cavity and the chin to the front, there is seldom any need for
interference. However, if the membranes are ruptured, and the head is not
coming into the os to dilate it, there must be some further complication
present, probably a small pelvis or an extra large head. If the condition
of the patient does not call for any active treatment wait until the os is
large enough to admit of internal version being performed. Should the
patient be showing signs of exhaustion, frequent pains, rapid pulse, etc., and
the dilatation being evidently delayed by absence of a dilator, put in a
Champetier de Kibes' dilating bag, and when the os is sufficiently large to
allow of version turn and bring down a leg.

In a few cases where the face is originally lying in the mento -posterior
position the chin rotates into the hollow of the sacrum. It is, therefore,
necessary in a mento-posterior case to do everything to make extension as
complete as possible, so that the chin may be inclined to rotate forwards.
Postural treatment is most valuable in causing extension. Place the
woman on the same side as that to which the foetal back is lying. This
produces an obliquity of the uterus which brings the direct intra-uterine
pressure into a line impinging in front of the centre of the head. When
there is a fully dilated os and the chin behind, try the postural treatment,
and wait two hours in the hope that the chin will rotate. If at the end of
that time it has not done so, it is best to turn the chin to the front, put on
forceps, and deliver. This is done by putting the left hand into the vagina
and the right on the abdomen. Grasp the face and turn it the shortest

LABOUR, MANAGEMENT OF 199

way to bring the chin to the front ; at the same time press the anterior
shoulder in the same direction.

If the chin cannot be rotated forward perforation is the only resource.

Brow

An average sized head cannot be delivered alive in this position. It is
therefore necessary always to convert a brow presentation either into a
vertex or a face. This can be done by completing flexion and producing a
vertex, or by completing extension, and then dealing with the resultant
face presentation as in the last section. (For mode of production and
mechanism see p. 173.)

Before rupture of the membranes; by the same methods as recommended
for transforming a face case into a vertex. If these fail push up the occiput
so as to try and get the chin down. If these manoeuvres fail the method
of procedure varies.

(a) When the head is above the brim and the os uteri partially dilated.
If the pains are infrequent, and the patient not exhausted, the best method
is to perform internal version and bring down a foot. If the pains, how-
ever, are frequent, and the uterus seems in a state of tonic contraction,
version implies risk of rupturing the uterus, and forceps should be tried.
Should these be unsuccessful perforation must be resorted to.

(b) When the head is in the pelvic cavity, but is not advancing. As
version would be dangerous to the mother, forceps must be tried if the
head is small. A strong pull will most probably extract the child. If the
pains are very strong, and labour has lasted some time, the head is in all
probability large, and if this is the case the forceps will fail to deliver the
head. Try first with the forceps, and if the head does not advance, perforate.

Podalic Presentations

The management of pelvic presentations, whether breech, knee, or foot, is
practically the same. (For cause and mechanism, see p. 174.) In these cases
the prognosis is usually good for the mother, but an increased risk to the
child. The duration of labour averages the same as in vertex presentation,
but with a full-timed child the process occupies a longer time. The low
average is accounted for by so many breech presentations occurring in
premature infants. It must also be borne in mind that the predisposing
factors for the malpresentation are present, and sometimes require special
treatment, and imply additional risks.

The diagnosis of breech presentations should be made out entirely from
abdominal palpation, and thus the possibility of rupturing the membranes
during a pain is avoided. It is well to tell the patient's friends that the
child is not presenting in the usual way, and that this circumstance may
possibly delay labour and entail additional risk to the child.

If the case is seen early enough, i.e. before rupture of the membrane, and
while the breech is movable, the question arises whether it would not be an
advantage to transform the podalic into a cephalic presentation.

This point must only be decided after a full appreciation of the fact that
in some conditions a podalic lie is preferable to a cephalic one. Thus in
placenta previa to turn and bring down a foot is the recognised treatment,
and in slight cases of pelvic contraction delivery of the aftercoming head is
more easily accomplished than the head coming first.

If these indications are not present there is no reason why the child

200 LABOUK, MANAGEMENT OF

should not be turned by external version. The best time to do this is when
labour has commenced. After doing so apply a tight binder to keep the
child in its new position.

If the breech presentation is to be allowed to remain the treatment
varies in the various stages.

First Stage. — The only treatment here, as in all cases of abnormal
presentation, is to preserve the membranes as long as possible, keep the patient
lying down to prevent undue straining, and avoid unnecessary vaginal
examinations. If the membranes rupture before complete dilatation of the
cervix the labour will be prolonged, and the risk to the child's life is
increased, as the breech is a very inferior dilator to the head. Further, as
the breech requires less room, delay is caused in delivery of the head from
want of previous complete dilatation.

Second Stage. — Do not be tempted to pull down a foot or leg in the
hope that it will hasten matters. Too early traction may result in the
head becoming extended, or the body may come down and leave the arms
extended by the side of the head, thus considerably increasing the difficulty
of delivery. Leave the case to nature until the trunk is born as high up
as the umbilicus. The only treatment required to this stage is to lift out
the feet as the breech slips out from the perineum, so as to prevent them
catching.

When the umbilicus is born pull down a hop of the cord. If this is
pulsating regularly the child is all right. Pulling down the cord also
prevents tension being put on the cord between the umbilicus and the part
caught at the brim.

If the cord is pulsating normally, wrap the body and legs of the body of
the child in a warm cloth, so as to avoid the risk of the cold air stimulating
the skin and inducing the child to respire. Usually the next pain drives
the child out with the exception of the head. The important point in
waiting for the pains is that the uterine contractions acting from behind
keep the arms flexed upon the chest, thus making delivery more easy. If the
child is pulled upon the arms will very likely extend. However, if the cord
is not pulsating, it is evident that in order to save the child the delivery
must be hastened as much as possible, the life of the child now depending
upon the skill and quickness of the practitioner. If the child has to be
pulled upon get the nurse to keep up firm and steady pressure over the
fundus during the manipulations. This helps to keep the arms on the
chest and the head flexed. Seize hold of the child round the pelvis, the
thumbs lying parallel to each other over the sacrum (this avoids injuring
the viscera from pressure by the finger), then pull downwards and forwards
until the scapulse are reached.

Delivery of the Arms. — Let the nurse draw the body of the child forward
over the .mother's abdomen. Then pass up the entire hand into the vagina,
and along the front of the child's chest, to feel for the arms. If they are
still flexed, pull them down by putting a finger first into one elbow and
then into the other ; this is quite easily done. If the arms are extended,
turn the child so that one arm lies to the front and back. It is best to
bring down the posterior arm first, as there is most room in the hollow of
the sacrum. Now with the body of the child held well forward over the
mother's abdomen, pass the hand into the vagina, so that its palmar surface
rests on the back of the child. Then place the first and second fingers on
the humerus, and slip them up until the elbow is reached, then with the tips
of the fingers press the elbow across the child's face. The anterior arm can
then be delivered as an anterior arm, or the body of the child can be rotated

LABOUE, MANAGEMENT OF 201

so that the anterior arm comes to lie in the hollow of the sacrum, and is
delivered in the same way as the posterior arm.

Occasionally the arm is extended and the elbow bent, and the forearm
lies behind the child's back. This is known as dorsal displacement of the
arm. This displacement in a full time foetus and a normally sized child
arrests the advance of the head, the displaced arm becoming caught on the
brim of the pelvis.

The position of the arm will be discovered when the hand is passed in to
deliver the arms. The arm can be set free by turning the body and pressing
the vertex towards the free arm. If this fails the arm may have to be frac-
tured before it can be brought down.

Delivery of the Head. — Unless the head is expelled by the same pain as
trunk and shoulders assistance is called for. This must always be effected
with the greatest rapidity. As a rule the head must be delivered within

Fig. 35. — The " Prague method " of extracting the head.

five minutes of the birth of the arms, or the child will be asphyxiated. The
danger to the child from any delay is due to the following causes : —

1. The pressure on the cord between the head and the bony pelvis will
stop the circulation.

2. The cold air stimulating the body of the child causes premature
respiration, and mucus or meconium is sucked into the lungs.

3. The placenta is very probably being detached.

The method of delivery depends upon whether the head is delayed in the
pelvic cavity or arrested above the brim. When the head is arrested in the
pelvic cavity the "Prague method" is the simplest and quickest method. With
the patient lying preferably on her back, the left hand is passed into the
vagina and passed up over the back of the child, and the first and second
fingers are hooked over the clavicles (Fig. 35). The limbs of the child are
wrapped in a cloth and grasped by the right hand. Carry the legs forward
over the mother's abdomen as far as possible, and by the joint pulling of the
two hands pull the neck and shoulders forward. The head is thus made to
roll out flexed from behind the perineum. The left hand pulls the shoulders
towards the anterior parts, and the pressure of the symphysis at the same
time presses on the occiput. Thus the head is flexed and is in the best
position for delivery.

202

LABOUK, MANAGEMENT OF

If the head is arrested above the brim, delivery can be effected by a

manoeuvre which combines jaw traction and pulling on the shoulder, or by

forceps.

The former method is the best, as there need be no unnecessary delay.

Jaw traction is especially suited for cases of arrest of the head above the

brim, but it can also be used if the delay is in
the pelvic cavity ; it is the most powerful as well
as the quickest method of delivery. The
practitioner, standing on the patient's right side,
passes the left hand into the vagina in such a
way that the child rides upon the arm
(Fig. 36). The two fingers are passed into the
child's mouth as far back as possible (this is
to lessen the risk of fracture of the jaw).

The right hand is placed over the shoulders
The fingers on the jaw prevent the head extend-
ing, whilst delivery is accomplished by traction
on the shoulders and jaw. If the resulting
flexion of the head is not sufficient, it can be
increased by placing the first and third fingers
of the left hand over the clavicles, and the second
finger pressing the occiput forwards. Pressure
on the abdomen is of assistance in hurrying up
labour.

When the head is above the brim the traction
should be first made backwards and down-
wards, and when in the pelvic cavity the direc-
tion is changed to forwards, at the same time

fig.36.— Method of jaw and shoulder carrying the body of the child well over the

traction for delivery of the head. ,,-. n4-V. pr'„ „ 1-.J „,-,-. prl
(After Chailly Honore.) LUOLIier S dUUOUien.

Forceps to the after-coming head are certainly
able to deliver the child, but they are slow. If the combined jaw and
shoulder traction does not succeed do not hesitate to at once apply forceps.
Forceps should always be ready for use in cases where there is any possibility
of difficulty in the birth of the head.

If forceps are used they must be locked under the body of the child, and
traction applied in the axis of the pelvis.

If the pulsations in the cord have ceased, and there is difficulty in ex-
tracting the head, it is best to use the perforator (for method see " Obstetric
Operations "), as it is less apt to damage the maternal parts than prolonged
pulling.

Difficult Breech Cases. — In a certain number of cases accidental com-
plications arise which make it necessary to assist the delivery of the breech.

In cases with a very large child, or a very small pelvis, or if the pains
are so feeble, there is great delay in the labour, and assistance is necessary
both for the sake of the mother, to save her from exhaustion due to want of
food, prolonged pain, and anxiety, and for the child, whose life may be
endangered from pressure on the cord. Also, if there is prolapse of a loop
of cord during the second stage of labour, the cord will have lost the protec-
tion the bent up legs would have given it, and therefore it is as well to
bring down a leg so that delivery can be quickly accomplished if the pulsa-
tions are evidently becoming arrested. It should never be forgotten that no
interference is justifiable before dilatation of the os.

Digital Pulling. — In cases where delay is due simply to weakness of the

LABOUE, MANAGEMENT OF 203

pains, steady pulling will accomplish delivery. Pass up the right forefinger
over the anterior groin between the abdomen and thigh, and during a pain
pull on the anterior groin. Whenever the breech is low enough pass in the
left hand and put two fingers into the posterior groin. Then whenever a
pain comes pull as strongly as possible. As the breech emerges, pull most
on the posterior hip, as it has the farthest way to come. This movement is
very useful, but is very tiring to the operator's fingers (often setting up
cramp).

If the pelvis is small or the child too big, there are several methods
recommended to assist delivery, e.g. bringing down a leg, or to deliver the
breech by traction with the fillet, blunt hook, or forceps.

Method of Bringing down a Leg. — It is best to ansesthetise the patient.
Then pass into the vagina the hand that will lie most easily flat on the
child's abdomen, placing the other hand over the fundus of the uterus. The
anterior leg will be found the most convenient to bring down. When the
fingers have reached the knee partial flexion is induced by pressing it out-
wards and backwards, and pass the hand up and seize the ankle with the
first finger and thumb. By pulling the ankle downwards the knee is
completely flexed. Then by further pulling on the ankle the thigh is
extended, and thus brought out of the uterus. Be careful only to pull on
the ankle. If this plan is to be adopted it should be done early before the
uterus has contracted tightly on the child. If the second stage has lasted
some time and the uterus is tightly contracted over its contents, it is better
to bring down the breech.

Traction on the breech by the fillet is carried out by passing over one or
both groins a silk pocket handkerchief or a bit of strong banding, which has
previously been boiled and then put into an antiseptic solution for a short
time. The end of the loop is seized and pulled upon ; the traction thus
applied is as a rule very successful.

The blunt hook is the easiest way of delivery in a really difficult case.
But unless used with very great care it is apt to injure the child's genitals
or lacerate the femoral vessels. If the child is dead the blunt hook can be
used without fear, and will quickly deliver (see " Obstetric Operations ").

Forceps may be applied to the breech, but the objection is that the.
ordinary shape of forceps is not suited to shape, and is very apt to injure the
child. Special forceps have been made, but they are required so seldom that
it is better to be prepared to deliver by simpler means.

Delivery of the Head in Cases with the Face Anterior. — The mechanism
of the delivery is described on p. 177. It is often impossible to deliver the
child without extensive lacerations. If the head is above the brim, pass the
hand up into the hollow of the sacrum behind the head, and then to move
the hand round until it reaches the mouth. This turns the head to the
side of the pelvis, which is the position in which the head can best pass the
brim. Should this fail forceps must then be tried, and if then unsuccessful
resort must be made to perforation. If the head is in the pelvic cavity, the
delivery can best be assisted by helping the head to flex further on the
chest, and the chin and the rest of the face to glide under the arch. This
is done by drawing the woman to the edge of the bed, depress the body of
the child, and carry it well backwards ; this draws the chin from behind the
symphysis. If the face sticks put the fingers far back into the child's mouth,
so that the face comes gradually out from behind the pubis, followed by the
forehead and occiput.

Injuries to the Child in Breech Deliveries. — In breech deliveries
where it has been necessary to assist nature in expelling the child, various

204 LABOUK, MANAGEMENT OF

injuries to almost all the different tissues and organs of the body have been
described.

Laceration and bruising may occur in the muscles of the neck and
back ; the best known one is hsematoma of the sterno -mastoid, caused by
haemorrhage into the sheath of the muscle. The tumour formed is usually
about the size of a pigeon's egg; it disappears gradually in about six
months, but is sometimes followed by permanent shortening, which is one
of the causes of torticollis.

Haemorrhage may also occur in the abdomen and cranium. The former
is due to injury to the liver and suprarenals, which can best be avoided by
only pulling on the trunk when grasping the pelvic girdle.

Meningeal haemorrhage and also haemorrhage into the brain substance
itself are fairly common, and may occur quite independently of fracture of
the skull bones. The late results of this injury are —

The genital organs are very liable to injury if the blunt hook is used.
Spiegelberg records a case where the penis and scrotum of a child were com-
pletely destroyed.

Paralysis of the brachial plexus has followed hard pulling on the
shoulders in order to deliver the head quickly. This occurs without an
accompanying fracture of the clavicle, and lasts from a few days to weeks ;
recovery invariably follows.

The spinal cord can be torn across in the cervical regions; this is
especially apt to occur in delivery of the head by the Prague method, the
whole force being transmitted through the neck.

Almost all the bones can be fractured. In the skull we meet with the
basilar portion of the occipital being separated from the squamous. The
parietal bones may be fractured. The vertebral column can be torn across.
This, as in cases when the spinal cord in the cervical region is injured,
occurs in cases that have been delivered by Prague's method.

Fractures of the clavicle and humerus occur, that of the clavicle
being fairly common. Fracture of the lower limbs sometimes is met with,
but is not usual. For methods of treatment see " New - Born Child,
Injuries of."

By putting the finger in the mouth various injuries have occurred ; e.g.
dislocation of the jaw and detachment of the condylar epiphyses may occur,
separation of the two halves of the lower jaw at the symphysis, or the jaw
may be dislocated, or the condylar epiphyses may be detached. The soft
tissues in the floor of the mouth may also be torn.

Transvekse Presentation

A transverse presentation so rarely rectifies itself, and the results of
allowing such a presentation to persist are so disastrous, that early treatment
is a necessity. (For " Causes, etc.," see p. 179.)

The various means at our disposal are : —

1. Postural treatment.

2. External cephalic version.

3. Internal or bipolar podalic version.

4. Embryotomy.

1. Postural Treatment. — In cases of slight obliquity of the uterus with
unruptured membranes this method is sometimes successful. The rationale
of the method lies in the fact that the breech and lower limbs of the foetus

LABOUK, MANAGEMENT OF 205

are heavier than the head, and therefore the breech tends to gravitate
towards the lowest point at the same time that the head rises. Thus, with
a head lying over the left iliac fossa the patient is placed on her left side,
and the breech tends to fall towards the left side, the head then rising
comes to He over the brim. This plan of treatment is only possible in a
very small proportion of cases in which the practitioner sees the case
sufficiently early.

2. External Cephalic Version. — This operation also requires un-
ruptured membranes and labour in an early stage. The foetus is turned
by external version until the head comes over the brim, when the mem-
branes are ruptured. The head should be held with the hand or by a tight
abdominal binder over the brim until it fixes. After version has been accom-
plished the child is very apt to slip back into the former position. It is,
however, quite worth the trial when possible, as it gives the child the best
chance of life.

3. Internal Podalic Version is indicated when external cephalic
version has failed, or cannot be performed. The version should be per-
formed as soon as possible and a leg drawn down ; the case can then usually
be allowed to finish as in a breech presentation.

There are, however, some contra-indications to the performance of internal
version, namely, If a considerable portion of the child is driven out of the
uterus, and when the uterus is in a state of tonic contraction with Bandl's
ring 2J inches above the symphysis. (Methods of performing version, see
article " Obstetric Operations.")

4. Embryotomy. — It may be necessary to do this under the following con-
ditions : — If podalic version is contra-indicated, for the reasons mentioned
above embryotomy must be performed. The main symptoms showing
that the uterus is in a state of tonic contraction are — persistent pains, and
the uterus continuously remaining hard instead of relaxing and contract-
ing, the presence of Bandl's ring about 2 to 2| inches above the symphysis,
increased pulse-rate, drawn, anxious expression, and the vagina in a hot and
dry state. Further, if the podalic version is difficult, and if there is reason
to believe that the foetus is dead, i.e. absence of fcetal heart sounds, and the
cessation of foetal movements, also, on feeling a loop of cord, the complete
absence of pulsation, the embryotomy is the best chance to the mother.
Or if podalic version is impossible from too much of the foetus having been
driven out of the uterus.

The best method of embryotomy to adopt in these cases is to pull down
the arm and decapitate. (The operation of decapitation is described in
article " Obstetric Operations.")

The choice of method to be adopted at the different stages are now
briefly given.

(a) The membranes unruptured and the os not sufficiently dilated to
admit two fingers.

At this stage do not interfere further than attempting to rectify the
position by postural treatment, or by performing external cephalic version.
Any further attempts would only rupture the membranes unduly early.

(b) The membranes unruptured, the os sufficiently dilated to admit two
fingers easily, but not fully dilated.

Here again postural treatment and external cephalic version should be
tried. If this fails there are two courses open to the practitioner, either to
remain beside the patient prepared to turn and artificially dilate the instant
the membranes rupture, or, if it is impossible to stay beside the patient
for hours, the best practice is to bring down a leg as soon as the size of

206 LABOUB IN MULTIPLE PREGNANCY

the os admits of it. The former method affords the best chance for the
child's life.

(c) The membranes are ruptured, the os is not sufficiently dilated to allow
of internal version (i.e. it will not admit two fingers easily). In these cases
dilate the cervix artificially by means of a Champetier du Kibes' dilating
bag. When the os is sufficiently dilated to allow of delivery perform internal
podalic version.

(d) The membranes are ruptured and the os fully dilated, the uterus being
moulded to the shape of the child. If the pains are not continuous, the
uterus relaxing, and the child movable between the pains ; listen for the
fcetal heart sounds, if the child is found to be alive, bring down a foot and
deliver by internal version. Should the uterus show symptoms of tonic
contraction, or there be unmistakable signs of death of the foetus, the best
method is to pull down an arm and decapitate.

Labour in Multiple Pregnancy

Introductory .... 206
The Anomalous Features of —
Maternal Risks . . . 207

Infantile Risks . . . 207
Management of 208

Complicated Cases . . . 209

Introductory. — Labour in multiple pregnancy is, as a rule, comparatively
easy, and yet the results to mothers and children are less favourable than
in single births. It is difficult to judge of the reason of this from the
occasional occurrence of twins in general practice, it is only when grouped
together in sufficiently large numbers and compared with ordinary labour
that one can realise wherein labour with twins differs from single cases.
Unfortunately statistics have generally been compiled in a form which
lessens their value for the purpose in view. Often the number of children
stated as born dead, includes, undistinguishably, the non-viable and decom-
posing, together with those lost in the birth ; the first and second born are
grouped together, instead of separately ; and the length of the interval
between the births, if given at all, is discussed apart from the results to the
children.

The data that will be here quoted, when not otherwise stated, are taken
from the Eeports of the Dublin Lying-in Hospital, published by Collins, by
Hardie and M'Clintock, and by Johnstone and Sinclair. The number of
women confined of twins was 568. The value of the statistics lies in the
fact that the sex and presentation of each child, the duration of the labour
and of the interval, the number of the pregnancy and the results to
mother and children, are given in the majority of the cases. Excluding
all children reported as " putrid " and those born before a viable age, there
were 538 cases available for analysis.

Anomalies. — The course of labour in multiple pregnancy is much the
same as in single births, but there are certain anomalous features which
have important bearing regarding management. Owing to a greater
tendency to pathological conditions, the labour is liable to be more or less
premature. The ratio of premature births has been estimated at as much as
26*5 per cent (Reuss).

The relative frequency of the various presentations is different from that
found in single births ; breech and transverse presentation are more frequent,
yet this, it will appear, is favourable rather than otherwise.

Both fetuses present by the head in about 50 per cent ; one head and the other
breech in 30 per cent ; both by the breech in 9 per cent. More rarely a head or a

LABOUR IN MULTIPLE PREGNANCY 207

breech presentation m<iy be associated with a transverse lie, the latter generally in
the second child ; both foetuses lying transverse is very rare (Spiegelberg).

Duration of Labour. — Multiple pregnancy rarely gives rise to difficulty
in labour, and in the vast majority of cases the natural powers are sufficient
to complete delivery. Conditions that retard the progress of labour are,
however, more frequently present. The delay occurs before the birth of the
first child, and chiefly, though not entirely, in the first stage.

According to the Dublin data, in single pregnancies 90 per cent of the cases
were completed within twelve hours, and 2 per cent only were protracted beyond
twenty-four hours ; whilst with twins, 90 per cent of deliveries was not reached
till fully twenty hours, and nearly 8 per cent were protracted over twenty-four
hours.

The cause of the delay is usually ascribed to " inertia due to over-disten-
sion " — an expression often used inaccurately. The over-distension which
causes delay in the first stage is not so much due to the increased bulk of
the fcetal bodies as to the relatively larger amount of liquor amnii commonly
met with in twin pregnancies ; and the delay is not owing to any inherent
weakness of the uterine muscle, but to imperfect transmission of the force
by the uterine contents. Owing to the relative excess of liquor amnii
the action of the bag of waters in dilating the os is liable to be defective —
a condition which is not peculiar to twin cases, but is frequently met with
therein. The prolonged ineffectual action so caused is liable to produce
secondary " inertia " of the uterus after the birth of the first child, leading
to delay in the expulsion of the second child and difficulty in the third stage
of labour.

The risks to both mothers and children are increased in multiple preg-
nancy. The maternal death-rate has been in some cases fully double, and
the infant mortality two and a half times greater than in single pregnancies.

Maternal Risks.— There is one cause that has a marked influence on the un-
favourable results, which must be mentioned although it is apart from labour, it
is, that in multiple pregnancy there is an increased tendency to eclampsia. In 568
twin pregnancies there were 7 cases of convulsions, or 1 in 81 cases, whereas in
ordinary pregnancies the ratio was 1 in 363 cases. The difference is not due to a
relative greater number of primipara in one series more than the other, for the
proportion, 30 per cent, was the same in both.

The great risk to the mother undoubtedly is increased liability to
haemorrhage after the birth of the children — dangerous in itself and pre-
disposing to complications in the puerperium.

The statistics of twin as compared with single births show that (1) post-partum
haemorrhage was five times more frequent; (2) the placentae were adherent twice
as frequently ; (3) retention of the placenta from all causes, necessitating manual
interference, occurred six times more frequently.

Various conditions here combine to increase the liability to haemorrhage,
there are the larger area of the placental site and an increased difficulty in
the separation and expulsion of the secundines, due to the larger placental
bulk to be expelled, and an apparent greater tendency to adhesion. To
these must be added the increased risk of uterine fatigue when the labour
has been retarded, causing slow and weak contraction and imperfect re-
traction.

Infantile Risks. — It has long been recognised that labour in multiple
pregnancy is specially unfavourable to the children, but more detailed
information on certain points than is generally supplied by writers is

208 LABOUK IN MULTIPLE PKEGNANCY

necessary to decide the question of the proper rules of treatment. Here
the Dublin data are of great value.

1. Length op Interval between the Births. — In 262 cases the interval was
stated ; of these the second child was born within fifteen minutes in 46"5 per cent ;
in the second quarter of an hour 30'2 per cent ; giving 767 per cent in the first half
hour. In the second half hour 9'9 per cent, and from one to twenty hours in 13-3
per cent.

2. The Mortality in relation to the Interval. — Of those born within the
first half hour, 1 in 20 was still-born ; of those in the second half hour 1 in 5 ;
over one hour 1 in 3'5, thus bringing out the important fact that the mortality of
the second half hour was four times greater than that of the first half hour.

3. Influence op the Presentation on the Mortality. — In the first born of
twins the mortality of head presentations was higher, that of breech and footling
distinctly less than in the same presentations in single births.

In the second born, head presentations were nearly twice as fatal as in the first
child, 11 per cent, as compared with 6 per cent. In breech presentations 2'5 per
cent only were lost. Of the children that lay transverse, and were consequently
turned, and of those that originally presented by the feet (132 in number), all ivere
bom alive. The result may be stated in another form. Of the still births 90"5 per
cent presented by the head, 9'5 by the breech, whilst among the footling and those
that were turned, there was not a child lost that was alive when the treatment
began.

4. Total Infant Mortality. — Exclusive of non-viable and macerated children,
the infant mortality in twin cases was 7'3 per cent, as compared with 2'7 per cent
in single births. Of the first children 6'8 per cent were still born, of the second 7'8
per cent.

Prematurity and feebler development may account for part of this high
mortality, but it does not explain the higher rate of the second born as com-
pared with the first ; nor the anomalous results regarding presentation, how
the more frequent occurrence of " abnormal presentations " tends to diminish
instead of increase the mortality.

Management of the Labour. — The above-noted facts show the in-
creased need of supervision, and the direction in which skilled assistance
may with advantage be extended. The presence of a second child is in
general unknown till after the birth of the first. Up to this point the
management is the same as in ordinary labour, but, thereafter, so anomalous
are the conditions and imminent the dangers, that one can no more rely
implicitly on the natural powers for the safe delivery of the child, than in
ordinary labour we trust to nature alone to expel the placenta. There is
the same need of supervision, the like dangers in the one case as in the
other. Instead of waiting half an hour, as text-books still recommend,
before rupturing the membranes, the delivery of the child should be com-
pleted within that time.

After the first child is born the unusual size of the uterus gives
indication of the presence of a second. The necessary attention having
been paid to the first born, and without any intimation to the patient of
the state of affairs, a vaginal examination should be made to complete the
diagnosis and ascertain the relationship of the foetus to the uterus. The
amniotic sac of the second child may be found ruptured, but usually it is
still entire. Dilatation being already complete, the function of the bag of
waters is gone, and nothing is to be gained by waiting for spontaneous
rupture. Without withdrawing the examining hand, or waiting for a pain,
the membranes should be broken, and still holding back the waters, the
necessary steps taken to secure command of the delivery. If the child lies
transverse, it must be turned ; if the breech presents, it is an advantage to
bring down one leg ; if it is a- head presentation two courses are open,
either to leave it to the natural powers, and trust to the forceps should

LABOUE IN MULTIPLE PKEGNANCY 209

delay occur, which is very apt to happen, or the child may be turned and
brought by the feet. In view of the unfavourable results given above,
where delivery was left to nature because of the presumed safety of head
presentations, and, on the other hand, the wholly favourable termination
when brought by the feet, there can be no doubt that version is the better
course. Under the conditions it is easy to perform and safer to both
mother and child.

Having got command of the delivery there is now no need of pre-
cipitate action. With the left hand steadily on guard over the fundus
intermitting traction can be made, and the child cautiously withdrawn,
even in the absence of uterine contractions, and this without fear of pre-
disposing to haemorrhage, for retraction is still active though contraction be
absent.

From what has been said above regarding the third stage of labour in
twin cases and the increased risk of haemorrhage, special attention at this
time is necessary, but the principles of treatment are the same as in
ordinary confinements. Greater difficulty and consequently longer time
may be required to complete the process of separation and expulsion. In
the absence of haemorrhage this may within normal limits be safely
allowed. There is more danger in precipitating this stage than in
facilitating the delivery of the second child. At the same time undue
delay may increase the difficulty, for in a partially emptied uterus delay
tends to irregular action, and an unequal degree of retraction of the uterine
walls, thus increasing the risk of post-partum hsemorrhage. The placentae
are usually expelled together, but when developed separately and occupying
distant sites, the placenta of the first born may come away before the birth
of the second child.

The same thing may occur where each foetus occupies the separate
halves of a double uterus, and so also may be explained the rare occurrence
of one foetus being retained in utero, it may be for weeks after the birth of
the other.

After the birth of a second child the possibility of a third or more must
be kept in mind.

Complicated Twin Cases. — Under various conditions, fortunately
rare, real difficulties may be experienced. These arise where both foetuses
occupy a single amniotic sac, or where the membranes of the further child
rupture before the birth of the nearer.

1. Different parts of each child may simultaneously engage in the brim,
as the head or breech of one and the feet of the other, or a foot of each
child. Care in ascertaining the relationship of the several parts is essential ;
with accurate diagnosis difficulty can be avoided, by operating on one child
at a time; with a head unable to enter the brim turning should be tried.

2. Interlocked Twins. — Two or more varieties have been described.
Where both foetuses present by the head, the difficulty arises when the

second head engages in the brim or has passed into the pelvic cavity along
with the neck and thorax of the first child. In the other variety, the first
is breech, the second head. When the trunk of the first child presenting by
the breech or feet is born, the progress of the after-coming head is
obstructed by the head of the second child having been pressed in
before it. Similar interlocking may occur where the second child lies
transverse. The difficulty in delivery under such circumstances will in all
probability be experienced before the operator is aware of the presence of
a second child. When recognised the actual relations of the two bodies
should always be carefully examined by the external as well as internal
VOL. vi 14

210

LABOUE, PEECIPITATE AND PROLONGED

methods, and it should always be remembered that in attempts at rectifica-
tion, external pressure in a proper direction by an assistant will facilitate
the process. The patient should be deeply chloroformed to check as far
as possible uterine action, for contractions but aggravate the conditions,
and waiting to see what nature may accomplish will increase the difficulty
by allowing an increasing amount of uterine retraction.

An effort should first be made by combined internal and external
pressure to raise the second head or other obstructing part above the brim,
and if successful it must be kept there by steady external pressure, whilst
traction by forceps or otherwise is made on the first child. Failing this,
the two heads in succession may be extracted by the forceps ; the small
size of the heads usually admits of this being done. If too large for the
size of the pelvis decapitation may be necessary. Under such circumstances,
as the child that first presents is the most likely to be lost, it is better to
sacrifice it, in the hope of being able to save the second child, which should
then be extracted by forceps without waiting.

3. United Twins (for varieties, see " Tekatology "). — It is surprising
how frequently the delivery of conjoined twins has been accomplished by
the natural powers, eighty-five times in 150 cases (Hohl and Playfair).
The presentation is always the same in the two foetuses. By the feet
is the more favourable, therefore, where possible, it is well to turn in
head cases, and if breech, to bring down all four feet. The diagnosis,
however, can rarely be made till the labour has considerably advanced.
When, however, the cause of the difficulty is investigated and two heads are
discovered, turning should, if possible, be adopted. In delivery by the
natural powers a process of spontaneous evolution has been observed, one
head and shoulders are born, then the corresponding trunk and limbs, the
lower portion of the other follows, and lastly its shoulders and head. It is
well, therefore, carefully to observe the mechanism that is taking place, and
aid as far as possible. In some cases evisceration may be necessary.

B. PATHOLOGICAL SECTION
Precipitate and Prolonged Labour

General View of Labour .

Precipitate Labour
Prolonged Labour

A. Primary Uterine Inertia

B. Secondary Uterine Inertia .

C. Premature Uterine Retraction

D. Obstructed Labour
Pelvic Deformities —

How the Shape of the Pelvis is

produced ....

The Common Kinds of contracted

Pelvis ....

The Flat Pelvis .

The Small Round Pelvis

The Small Flat Pelvis .

Rickety Deformities of the
Pelvis : the Flat Rickety
Pelvis, the small Flat Rickety
Pelvis, the Scolio - Rachitic
Pelvis

211
211
212
212
213
214
215

218

219

220
220
220

221

The Mechanism of Labour with

Contracted Pelvis . . . 224
Labour with the Flat Pelvis . 225
Labour with the Small Pound

Pelvis 227

The Rare Forms of Contracted

Pelvis 229

The Funnel-Shaped Pelvis . 229
The Oblique Pelvis of Naegele 230
The Transversely contracted

Pelvis of Robert . .231

The Kyphotic Pelvis . . 232
TheKyp>ho-Scolio-RachiticPelvis23±
The Osteomalacic Pelvis . .235

The Pseudo- Osteomalacic Rickety

Pelvis . . . . 23&

Spondylolisthesis . . .237

Spondylizema. . . .239

Effect of Fracture and of Hip-
Disease on the Pelvis . . 240

LABOUK, PKECIPITATE AND PKOLONGED

211

The Diagnosis of Contracted

Pelvis .

240

Pelvimetry .

240

I. External . . . .

240

II. Internal . . . .

2 1 2

The Treatment of Labour with

CONTACTED PELVIS

246

Abortion .

247

Prevention of Pregnancy

247

Ccesarean Section .

247

Cephalotripsy

247

Premature Labour .

247

Symphysiotomy . . . 248

Forceps ..... 250

Turning .... 250

8low Dilatation of the Os Uteri 251

Cicatricial Contraction of Os . 252

Congenital Smallness of Os . 252

Labour with Cancer of Cervix. 252

,, Ovarian Tumour 253

,, Uterine Fibroids . 254

,, Tumours of Pelvic

Pones . .255

is about eighteen hours. The
the os uteri. This opening is
and has to be enlarged from

Labour is a mechanical process, which consists in the forcing open of
the genital canal to a size large enough to let the child pass. The genital
canal is in the bony pelvis ; but with a child of not more, and a pelvis
of not less than average size, the child can pass without resistance from
the pelvic bones, the only obstacle to its birth being the muscular and
fibrous tissues of the pelvic floor.

The average duration of first labours
first stage consists in the dilatation of
bounded by thick flbro-muscular tissue,

about the size of a quill to a diameter of about four inches. Its expansion
takes about eighteen hours. The second stage consists in the dilatation of
the vagina and vulva. This part of the genital canal is larger and more
distensible than the os uteri ; its dilatation therefore only takes about two
hours. Its narrowest part is the vaginal orifice, and here the dilatation is
always completed by tearing. When the canal has been opened up in
former labours, it dilates more quickly ; in labours not the first the
dilatation of the os uteri takes about eleven hours, and of the vagina and
vulva about half an hour.

The , foregoing figures are averages. The time occupied in any in-
dividual case depends upon three factors which Alex. Simpson has happily
named the " Powers, the Passenger, and the Passage : " first, the strength of
the pains, and the down-bearing efforts with which the mother accompanies
them ; second, the size of the child, which conditions the amount of dilata-
tion required ; third, the dilatability of the parts.

If the child is very large, or if the pelvis is small, there may be resist-
ance not only from the soft parts but from the bones, so that the child can
only pass by altering its position in respect to the pelvic bones, and by
alteration of the shape and size of its head by moulding.

From alterations in the factors which have been specified, labour may
be either very quick or very prolonged. Very quick labour is called
" precipitate " labour.

Precipitate Labour

Precipitate labour implies that the child is not large in relation to the
pelvis. The labour may be quick (a) because the soft parts easily dilate,
the powers being either normal or unusually vigorous. The only harm
that comes from this kind of precipitate labour is such as follows from the
child being expelled before the mother expects it. It may be driven out
while the mother is at the watercloset, or in a vehicle, or standing. In the
latter case, the sudden pull upon the umbilical cord as the child drops often
tears it through close to the umbilicus. The muscular fibres of the torn
arteries usually closes them, so that they bleed not. If the cord is too

212 LABOUB, PEECIPITATE AND PKOLONGED

tough to tear, and not long enough to let the child lie on the floor, the pull
upon the placenta may, after uterine contraction has passed off, invert the
uterus. This is the sole danger arising from this kind of precipitate labour.
Labour may be precipitate (6) because the powers are excessive ; either the
uterine action is exceptionally strong or the mother's down-bearing efforts
are excessive. In either case the effect may be that the child is forced
through the genital passage without time being given for this passage to
dilate? The result is, that the parts are torn instead of stretched open,
and bad lacerations of the cervix uteri, vagina, and perineum are the result ;
the last named being the most important. Cases have been recorded in
which rupture of the sternum, subcutaneous emphysema, and cyanosis
have been the result of the mother's excessive straining.

The treatment of 'precipitate labour consists in two things : first, to keep
the mother recumbent ; second, to abolish excessive down-bearing effort by
the administration of chloroform. In some cases, as for instance when
valvular disease of the heart is present, the latter measure is of high
importance.

Prolonged Labour

Prolonged labour may result (1) from weakness of the powers ; (2) from
large size of the passenger ; (3) from anomalies of the passage, (a) of the
bones, (6) of the soft parts.

(1) Weakness of the powers. We know hardly- anything of the
conditions which determine the strength and rapidity of uterine action
during labour. We have no data from which, when consulted by a
pregnant woman, we can predict that, other conditions being normal, her
labour will be quick or slow. Uterine action depends not upon the
general health. Women in the last stage of phthisis have been known
to have quick deliveries; and lingering labour has been observed in
women of robust health and powerful build.

Uterine Inertia

There are three forms of weakness of pains : A. Primary uterine inertia.
This means that the uterine contractions are infrequent, short, and weak.
As Dakin puts it, " The process is leisurely." We know almost nothing of
the causes of primary uterine inertia. It is annoying to the accoucheur,
because it wastes his time ; wearisome to the patient's friends ; and tire-
some to the patient herself, because she has to wait so long _ for her
baby ; but it is attended with no danger and no additional suffering. All
the treatment wanted is time. The chief danger is lest the accoucheur's
impatience should overmaster his judgment, and make him set about pre-
mature forcible delivery. There are some conditions which help to produce
it. Too much liquor amnii by over-stretching the uterus, will weaken
it, and thus cause weakness of pains. Too close adhesion of the membranes
to the uterus sometimes prevents the bag of membranes from moving
on as it should do, pressing into, and dilating the circle of the os. This
will cause labour to be slow, for the stimulus of the pressure upon the os
uteri which should provoke reflex uterine contractions is absent. In such
a case, if the finger is inserted, and swept round the lower segment of the
uterus, so as to separate the membranes as far as possible, the bag of
membranes will be enabled to move on, and to press into the os uteri ; and
more frequent uterine contractions will follow as a reflex effect. To this
cause is due the weakness of pains so often present in cases of placenta

LABOUR, PRECIPITATE AND PROLONGED 213

prsevia : the placenta being attached round the os uteri is separated with
more difficulty than the membranes, and hence more slowly protrudes into
the os, and less effectively stimulates uterine contraction. The artificial
separation of as much as possible of the placenta when it is prsevia, has long
been recognised as good practice, and it acts in the same way as the artificial
separation of the membranes. The strength or frequency of uterine con-
tractions cannot be influenced by the will, although the uterine action may
be helped during the second stage of labour by the abdominal muscles. The
action of the uterus is influenced by emotion ; the entrance of the accoucheur
often, to use women's phrase, " frightens away the pains." Fulness of bladder
and rectum are commonly assigned as causes of uterine inertia, though it is
difficult to explain how. If either viscus is full it should be emptied, by
catheter or enema if the patient cannot relieve herself. The bladder is
usually drawn up out of the pelvis into the abdomen during the second
stage of labour ; but if prolapse is present, the bladder may so sink that
when full it obstructs the progress of the head, and the head may then pre-
vent the bladder from being drawn up. If the rectum is allowed to con-
tinue full, the descending head will have to squeeze out the fseces before
it ; a process which delays delivery, and is annoying to the accoucheur.

B. Secondary uterine inertia : also called " uterine exhaustion " : or
" temporary passiveness."- — This means, that after uterine contractions have
for a time recurred with average frequency and been of average strength,
they get less and less frequent, and usually also less and less vigorous.
The patient may go for hours without a pain. The progress of the labour
is during this time almost suspended : but some uterine retraction may
go on, though pain is absent. If nothing is done, the patient will go to
sleep : and by sleep nervous energy will be recuperated, and then uterine
action will recommence with frequency and vigour. This condition is free
from danger, excepting such as may result from the impatience of the
accoucheur. If he will not wait for the return of uterine action, but drags
the child out while the uterus is passive, post-partum hsemorrhage is likely
to follow. This is the explanation of the well-known fact, that there are
some medical men in whose practice post-partum hsemorrhage is common,
while others hardly ever meet with it. Those who get hsemorrhage are
those who drag the child away while the uterus is not acting. It is true
that delivery in the absence of a pain is not invariably followed by
hsemorrhage. This is because uterine action is essentially intermittent ;
so that a long interval without a pain does not always mean that uterine
exhaustion is present. Towards the end of such an interval uterine con-
tractility may have returned, and if then the patient is artificially delivered
the stimulus of the accoucheur's manipulations may provoke uterine con-
traction. But forced delivery, while the uterus is exhausted, will certainly
be followed by dangerous hsemorrhage in the third stage. The men who
get no post-partum hsemorrhage are those who act on the rule never to
deliver in the absence of uterine action : to pull in order to help uterine
contractions, not to replace them.

Diagnosis. — It is most important to distinguish between secondary
uterine inertia and tonic contraction of the uterus. The distinction is,
as Braxton Hicks used to put it, the very " keystone " of sound practice
in midwifery. There are superficial resemblances. In both rhythmical
pains have ceased, and in both the patient and her friends may be alarmed
at the delay, and clamour for speedy delivery. In tonic contraction of
the uterus from obstructed labour, the patient's expression is one of
anxiety ; her pulse is quick, 120 or more, and gets quicker and quicker

214 LABOUB, PEECIPITATE AND PEOLONGED

the longer the condition lasts ; the uterus felt by the abdomen is of un-
changing hardness : by the vagina the presenting part is felt pressed
down and fixed in the pelvic brim. In uterine inertia, on the contrary,
the patient's expression is placid, her pulse is usually under 100, and of
normal volume. By the abdomen, the outline of the child's body can be
felt with unusual ease, and easily moved about. By the vagina, the pre-
senting part of the child can easily be pressed back. In labour obstructed
from excessive size of the child there is a large caput succedaneum, so
that suture and fontanelles cannot easily be felt, and there is swelling
of the vagina below the head : but not so in uterine inertia.

The treatment of secondary uterine inertia is to imitate and help
nature by letting the patient sleep, or if sleep come not, to procure it by
chloral or opium. Give a grain of opium, or fifteen minims of laudanum,
or half a drachm of chloral ; and if in half an hour the patient is not
asleep, repeat the dose. I place the opium first, because opium can be
conveniently carried in the form of one grain pills, which neither eva-
porate nor stain the bag or pocket. When the patient awakes, uterine
action will return with increased force and frequency, and the labour will
usually be quickly ended.

C. Premature uterine retraction. — This is a rare condition, first described
by Litzmann, and made known to the profession in England by Matthews
Duncan. In it, when the liquor amnii has escaped, pains follow one
another rapidly, and the patient's manifestations of suffering make it seem
that they are strong ; the uterus becomes contracted round the child ; and
the retraction ring is drawn up. The condition of the uterus is like that in
obstructed labour ; but — there is no obstruction. I have seen one case. I
was sent for by Mr. T. E. Fendick to help him with a lingering breech
labour. I found a patient, very nervous, and intolerant of interference, and
who thought herself seven months pregnant ; a uterus reaching to one-third
of the distance between the umbilicus and the ensiform cartilage ; a capacious
pelvis ; the os uteri well dilated. I told Mr. Fendick that a little time was
all that was wanted ; that the child was small, the pelvis roomy, the os
uteri open, and that there was therefore nothing to hinder delivery.
Several hours afterwards I was again sent for. I was told that the patient
had been having strong pains ever since my visit, but without advance. I
found the state of things on vaginal examination unaltered. I passed my
hand into the uterus with ease, and felt a ring of contraction high up,
several inches above the pelvic brim, encircling the child's feet and shoulders.
I seized a foot and brought it down, and delivered the child without
difficulty in a few minutes.

This condition resembles obstructed labour, except in the fact that
there is no obstruction. The contractions of the upper part of the uterus
instead of driving down the child, have stretched the lower segment of the
uterus. Why or how this condition comes about, we know not. I have seen
early in the first stage of labour very frequent and painful uterine contrac-
tions which, although recurring for a long time, produced very little effect
in opening up the cervix ; and I have seen these contractions made less
frequent, more effective, and less painful, by antipyrin : a drug which acts in
like manner in painful uterine contractions during pregnancy, after delivery,
and during menstruation. I conjecture that if these very frequent painful
and ineffective uterine contractions were to go on, premature uterine
retraction would be produced ; but this is only a conjecture ; I have not
watched the one pass into the other. When premature uterine retraction
has come about, the right and only treatment is to deliver, either by forceps,

LABOUK, TKECIPITATE AND PKOLONGED 215

breech traction or podalic version, according to the presentation. As there
is no obstruction, delivery is easy.

The conditions just described are those in which uterine action is weak.
I now have to describe the condition which conies about when the uterus is
strong, but delivery is mechanically impeded.

1). Obstructed Labour. — This is the condition which comes about if the
child cannot pass through the genital canal and labour is allowed to go on.
The child may be unable to pass either because it is of excessive size, or
because the pelvis is contracted, or the child is lying in a wrong position
and is too big to pass in the faulty position, though it might have passed in
a right position. It is not possible to define how large a child can pass
through a normal pelvis, because its passage depends not only on its own
size, but on the degree of ossification of its head, and on the size of the
pelvis. With a pelvis of full average dimensions, and a child of not more
than average size, there is abundance of room, so that if the pains are
strong enough and the head soft enough to be moulded, the child can pass
in almost any position. If it lies transversely, strong pains can expel it
living by the process called the spontaneous evolution of Douglas. If the
face or the brow present, a soft head of an average-sized child may be so
moulded that it can get through if the pains are strong enough. But
children lying in unfavourable positions are often too large, and the uterine
action is not often strong enough to drive a child in an unfavourable
position through the pelvis.

When the child's progress through the pelvis is mechanically impossible,
or possible only under exceptional conditions, a skilful accoucheur ought to
find this out at the beginning of the labour, and apply proper treatment
before the mother's condition has suffered. If the accoucheur is not skilful,
or is not sent for in time, the condition known as obstructed labour gradu-
ally develops. We owe our knowledge of this condition to Braxton Hicks,
who was the first to carefully observe it. When labour is obstructed the
pains follow one another with increasing rapidity, the pauses between them
get shorter and shorter until at length there is no pause, but the uterus is
in continuous contraction. While this is going on the liquor amnii gradu-
ally drains away, and the uterus becomes more and more closely moulded
to the body of the child. The child hence loses its mobility, and the
pressure of the most salient and hard foetal parts upon the parts of the
uterus opposed to them becomes continuous. These parts suffer from the
pressure ; the uterus becomes tender, and the damage by pressure makes it
prone to become inflamed after delivery. The continuous pressure hinders
the circulation through the placental site upon which the supply of oxygen
to the foetus depends, and may thus kill the foetus by asphyxia. If the
cord be wound round a hard part of the foetus, it is possible that the con-
tinuously contracting uterus may so compress it as to stop the circulation
through it and thus kill the foetus.

The uterine contractions expend much nerve force ; and the faster they
occur and the longer labour lasts, the greater the strain upon the nervous
system. The pain also depresses nervous tone, and to these things is
added want of sleep, for the patient cannot sleep while labour is actively
going on. When a large head is impacted in the pelvic cavity there is a
further source of pain in the pressure on the sacral nerves ; but this is of
less importance in the exhaustion of the patient than the causes mentioned
before. From these causes it results that the continuance of obstructed
labour is accompanied with progressively increasing exhaustion of the
patient. This is marked by the pulse becoming quicker and smaller, the

216

LABOUE, PKECIPITATE AND PEOLONGED

facial expression anxious, the patient restless, her lips parched and her
tongue brown. If her condition continues unrelieved she will die.

If the existence of disproportion is not recognised, and ergot is given,

the symptoms of obstructed labour will
develop more quickly, and if proper
treatment is not applied, the fatal
termination will come sooner.

The upper part of the uterus is
that which contracts; the lower part,
that below the equator of the foetal
head, has to dilate, and is pulled by
the upper part up over the head. When
obstructed labour has lasted long,
the upper part of the uterus becomes
thick, and the lower segment thin.
The line where the thick part joints
the thin, can sometimes be felt
through the abdominal wall, and is
called the ring of Bandl, after the
Austrian obstetrician who first de-
scribed it.

When there is no hindrance to the
pulling up of the cervix uteri, the
lower segment of the uterus, the
cervix, and the vagina, are all equally
stretched, and the junction between
the contracted upper part and the
Labour fetched lower part is not always
marked by an abrupt change in
thickness. The protracted pressure of the foetus upon the stretched part of
the genital canal may cause it to give way, and thus rupture of the uterus

Fig. 1. — Diagram showing thickening of the
upper part of the uterus, thinning and steetch
ing of the lower uterine segment,
obstructed by hydrocephalus.

Os externum

Ring of Bandl.

Fig. 2. — Showing thinning of lower uterine segment. (Drawn by Dr. T. W. P. Lawrence, from a specimen in
the Museum of the University College, London, by permission of Sir T. Williams.)

or vagina occurs. When the lower part of the uterus and the vagina are
equally tense, the one is as likely to give way as the other.

(2) In some cases of obstructed labour a different effect is produced.
When the head presents and is too big to enter the brim, it cannot come
down far enough to enter the os uteri. The bag of membranes enters the
os uteri, and the part unsupported by the cervix uteri receives the full
pressure of the uterus upon the liquor amnii. It therefore protrudes more
than it does in normal labour, the liquor amnii contained in it and called
the " forewaters " not being as in normal labour cut off by the head from
the bulk of the liquor amnii. This abnormal pressure upon the part of the
membranes protruding through the os, ruptures them long before the os
uteri is fully dilated. Then the head nips the cervix uteri between it and
the symphysis pubis. As labour goes on, the upper part of the uterus con-

LABOUR, PRECIPITATE AND PROLONGED

217

tracts more and more, pulling up the lower segment. But the cervix
cannot rise, being held down where it is nipped between the head and
the pubic bones. The lower segment therefore becomes more and more
stretched and thinned, and the boundary between the upper part of the
uterus which contracts, and the lower part which dilates and thins, becomes
more and more abrupt. This line of sudden alteration in the thickness of
the uterine wall is the ring of Bandl. Much discussion has taken place as
to the part of the uterus at which it is formed. Some have maintained
that it is identical with the internal os. I think that it is above this, and
that it cannot be more exactly defined than as the part of the uterus which

RETRACTION
RING

EXTERNAL^
VAGINA

Fig. 3. — Ruptured uterus, showing retraction ring at level of firm attachment of peritoneum ; thinning of
cervix ; gradual thinning of lower uterine segment from retraction ring down to os internum. A, Firm
attachment of peritoneum. (From a specimen in the London Hospital Museum.)

corresponds to the equator of the foetal head, is situated at the brim of the
pelvis, and is nearly that of firm attachment of the peritoneum. If
obstructed labour still goes on, and the patient dies not from exhaustion,
rupture of the uterus will take place, the rent being in the stretched and
thinned lower segment.

The symptoms, physical signs and treatment of rupture of the uterus,
are described.

The prolonged pressure upon the soft parts nipped between the foetal
head and the symphysis pubis, often produces sloughing of these soft
tissues, and the formation of urinary fistulse. These will be found described
elsewhere.

In the preceding pages four kinds of abnormal uterine action have been
described. In the three first, if they occur in labours otherwise natural, it
may be correctly said that labour is prolonged through fault in the powers,
and through that alone. In the fourth, the abnormal uterine action is
secondary, and a result of the exceptional difficulties which the uterus has

218

LABOUK, PEECIPITATE AND PKOLONGED

to overcome ; but it is nevertheless a fault in the powers, and therefore I
have here described it.

To make this account complete I must add, that labour may be slow
because the auxiliary forces, the down-bearing efforts of the patient, are
absent, as in paraplegia. But this is very rare ; it never prevents delivery,
though it may delay it. The only treatment is to supplement uterine
action by pushing from above or pulling from below.

(3) I now have to describe the faults in the passage which make labour
difficult. These are of two kinds : (a) in the bones ; (b) in the soft parts.
I take first obstruction by the bones ; in other words, contraction of the
pelvis. I shall describe the production, characteristics, effects, diagnosis,
and treatment of those pelvic deformities which are common enough and
great enough to be obstetrically important.

Pelvic Deformities

The shape of the female pelvis is determined by three factors :

(1) The innate tendency of the bones to grow into their proper shape;

(2) The pressure of the weight of the body through the vertebral

Fig. 4. — Pelvis of fcetus at term.
(After Balandin.)

-Pelvis of adult. (After
Balandin).

column on the sacrum, which it presses downwards and forwards,
and the reacting pressure of the femora upon the acetabula, which they
press upwards ; (3) The pull of muscles and ligaments upon the pelvic
bones. Deformed pelves are produced by altered effects of these forces :
(1) The bones may be stunted in growth either uniformly, or in special
places ; (2) They may be softened by disease, so that they yield unduly
to pressure and pulling; (3) Muscles and ligaments may be displaced
by disease or accident so that they come to pull in an abnormal way.
In many pelvic deformities these three agencies are combined, so that
it is difficult to separate the action of each force, and there has been,

LABOUR, PRECIPITATE AND PROLONGED 219

and still is, difference of opinion as to the way in which certain deformities
are produced.

At birth the sexual differences between the male and female pelvis are
already evident, although they are not so marked as later in life. The differ-
ences between the infantile and the adult pelvis are more marked (Figs. 4, 5).
In the foetus the sacrum is less curved from above downwards than in the
adult. The sacral promontory is high above the plane of the brim. The
transverse diameters of the pelvis are narrower in proportion to the others
than in the adult. The vertebral column is nearly straight ; the lumbar
convexity and the dorsal concavity hardly exist. As the child grows up
the curves of the spine are produced. The body weight presses the sacral
promontory downwards and forwards ; this increases the curve of the
sacrum from above downwards, and presses down the promontory until it
comes to be very little above the plane of the brim.

The pressure of the body weight upon the sacrum can be split up into
two components, one acting downwards and backwards, the other downwards
and forwards. The former tends to force the sacrum downwards between the
two innominate bones ; the latter tends to force the promontory forwards
towards the symphysis. It is obvious that the relative magnitude of these
two components will vary with the inclination of the pelvis. The less the
pelvis is inclined to the horizon the more the sacrum will be driven down
and the less it will be driven forward. The greater the inclination of the
pelvis to the horizon, the more will the sacral promontory be driven forwards.
This theoretical reasoning is unimpeachable. But it has never been shown
that the projection of the sacral promontory does in fact vary with the pelvic
inclination. The pelvic inclination, whatever it may be in the somewhat
artificial conditions under which it
has been measured, is continually
varying in different postures. So
that I think the pelvic inclination,
although a factor in modifying the
shape of the pelvis, is not a factor
of the first importance.

The femora press directly up-
wards. As the acetabulum is out-
side the line along which the body
weight is transmitted, viz. one from
the sacruni to the feet, the pressure
of the femora tends to force the
acetabula outwards as well as up-
wards. This pressure is resisted by
the ligaments of the pubic sym-
physis, Which hold the pubic bones Fig. 6.-Sagittal section of normal pelvis. AB, True
together. When these ligaments conjugate; AC Diagonal conjugate; CD antero-

° to posterior diameter of outlet. (After Pmard.)

are divided, the pubic bones fly

apart, and if the femora are pressed upwards the pubic bones diverge
yet more. Hence the combined influence of the downward pressure of
the sacrum and the upward pressure of the femora is to widen the pelvis.
The widening is also aided by the growth of the lateral masses of the
sacrum, which is wider in proportion to its length in the adult than in the
child, and by the growth of the ilia. In the child, the posterior half of
the pelvic ring is formed almost entirely by the sacrum ; but in the adult,
the sacrum only forms a part of it, the rest being formed by the ilia.

These normal developmental changes vary in degree, from causes that we

220

LABOUK, PEECIPITATE AND PKOLONGED

know not ; just as some members of the same family grow tall, others short :
we know not why. If the changes that have been described proceed to an

excess, the promontory of the sacrum
is lower down and further forward,
and the sacrum is more curved from
above downwards than it should be.
The conjugate diameter at the brim is
then less than the average, but the
other measurements of the pelvis are
of average size. A pelvis of this
shape is called a flat pelvis. It is one
of the commonest pelvic deformities.

Sometimes the normal develop-
mental changes are deficient in degree.
The pelvis does not increase in breadth
as it ought to do. The sacrum may
be straighter than usual, and the pro-
montory higher. Such a pelvis, con-
tracted mainly in its transverse
measurements, is called the generally
contracted pelvis ; the pelvis mqualioiter
justo minor, or the small round pelvis. Sometimes the two conditions
just described occur together : the growth of the ilia and lateral masses of
the sacrum is defective, and so the pelvis does not attain its normal

Fig. 7.— Sagittal section of fiat pelvis. AB, True
conjugate ; AC, diagonal conjugate ; CD,
antero-posterior diameter of outlet. (After
Pinard.)

Fig. 8. — Diagram of the generally contracted flat non-
rickety pelvis ; black line normal pelvis ; dotted line
contracted pelvis. E, sacral concavity and brim ; BB,
sacrum; CC, transverse diameter; DD, ilio- pectineal
eminence ; A, symphysis.

Fig. 9. — Diagram of pelvic cavity of generally
contracted fiat non- rickety pelvis. AB,
true conjugate ; AC, diagonal conjugate ;
CD, antero-posterior diameter of outlet.

breadth, and, at the same time the promontory of the sacrum is driven
unduly forward and downwards. Then a pelvis is produced which is
contracted in the conjugate diameter and in the transverse diameters also.
This form of pelvis is called the generally contracted and flattened pelvis,
or the small flat pelvis.

In the forms of contracted pelvis just described, there is no evidence of
any disease of the bones, and there is no deformity elsewhere. The
patients are often undersized, but they may be of average stature, or
even above the average. We know nothing as to why these defects in
growth occur. These minor degrees of pelvic contraction are not accom-
panied with any peculiarities of attitude or gait : they can only be detected

LABOUE, PEECIPITATE AND PEOLONGED

221

by careful examination and measurement of the pelvis. The flat pelvis and
the small round pelvis are the commonest kinds of pelvic deformity. I
know of no trustworthy statistics showing how common they are in
England. The practice of lying-in hospitals and of specialists gives not a
true representation of their frequency, for patients go to such places and
persons because they are known or suspected to have contracted pelves.

Two rare kinds of pelvis are often described as varieties of the small
round pelvis. One is the dwarfs pelvis. This is a pelvis which is like the

Fig. 10. — Sagittal section of small round
pelvis. A B, true conjugate ; AC,
diagonal conjugate ; C D, Antero - pos-
terior diameter of outlet.

Fig. 11. — Diagram of the brim of the same round pelvis ;
black line, normal pelvis ; dotted line, small round
pelvis. B B, sacrum ; C C, end of transverse diameter ;
D D, ilio-pectineal eminences ; E, centre of sacrum in
plane of brim ; A, symphysis.

rest of the skeleton of a dwarf in being diminutive in size, but not
deformed in shape. Females whose growth is so stunted that they may
be properly spoken of as " dwarfs " are generally sterile. I know of no
account of labour in a dwarf. The other is the small round rickety pelvis.
This is simply a small round pelvis A

without any rickety deformity, occur-
ring in a patient who has signs of
rickets, or what are taken to be such,
in some other part of the body. I
see no reason, in such a case, for
labelling the pelvis with the adjective
" rickety."

The commonest cause of great con-
traction of the pelvis is rickets. The
features of this disease which are
important obstetrically, are softening
of the bones and enlargement of the
epiphyses. The bones being soft
during part of their time of growth,
yield excessively to the forces which
mould the shape of the pelvis. The sacrum, yielding to the body weight,
sinks further downwards and forwards than it ought to do, and hence the'
conjugate diameter of the brim is shortened. The body weight falls on the
upper part of the sacrum. The lower sacral vertebrae are not exposed to
this pressure, but are held up by strong ligaments which connect them
with the ilia. Hence the sacral curve from above downwards is exaggerated,
the upper part of the bone being abruptly curved forwards. The body

c d

Fig. 12.— Diagram of the cavity of the small round
pelvis. AB, true conjugate; AC, diagonal con-
jugate ; C D, antero-posterior diameter at out-
let ; continuous line, normal pelvis ; dotted
line, contracted pelvis.

222

LABOUB, PEECIPITATE AND PEOLONGED

weight falls upon the middle of the bone ; the sides are held up by their
ligamentous attachments to the ilia. Hence the middle of the sacrum is
bulged down, and its anterior surface becomes convex from side to side,
instead of concave, as in a normal sacrum. The downward pressure of the
body weight is transmitted through the ilia to the femora, and by them to
the legs and feet ; its direction, therefore, is along a line from the sacrum

Fig. 13.— Sagittal section of flat rickety
pelvis. AB, true conjugate ; AC,
diagonal conjugate ; CD, antero-posterior
diameter of outlet.

Fig. 14.— Diagram of rickety flat pelvis. BB, sacrum at level of
brim ; CC, transverse diameters ; DD ilio-pectineal emin-
ences ; A. pubes ; continuous line, normal pelvis ; dotted
line, contracted pelvis.

to the feet. The acetabula are situated outside this line ; the femora there-
fore press the acetabula upwards and outwards, and so widen the pelvis. As
the acetabula are pressed upwards and outwards, the ilia are pressed in the
same direction, and the iliac fossae come to look more forwards and less

g d

Fig. 15. — Rickety flat pelvis . AB, true conjugate ;
AC, diagonal conjugate ; CD, antero-posterior
diameter at outlet ; black line, normal pelvis ;
dotted line, contracted pelvis.

Fig. 16. — Diagram of brim of small fiat rickety
pelvis. BB, sacrum ; B, centre of sacrum in
plane of brim ; CC, transverse diameter ; DD,
ilio-pectineal eminence ; A, symphysis pubis ;
continuous line, normal pelvis ; dotted line, con-
tracted pelvis.

inwards than in the normal pelvis, so that the iliac crests, instead of at
their anterior parts curving inwards, run directly forwards, or even forwards
and outwards. The ilia are slightly rotated about an axis parallel with
the sacro-iliac synchondrosis, so that the posterior iliac spines are nearer
together than in the normal pelvis. The trochanters are, with relation to
the pelvis, further upwards and outwards than normal, and this involves
an extra pull in an upward and outward direction, upon the muscles
running from the ischia to the trochanters. Hence by slight eversion of

LABOUE, PKEC1PITATE AND PEOLONGED

223

the ischial tuberosities the outlet of the pelvis is a little widened. The
epiphyses in rickets are enlarged ; hence in the rickety pelvis the epiphyses
of the sacral vertebrae can be felt as ridges running across it, and the
symphysis pubis is thickened.

Eickets is accompanied with stunting of growth. Hence rickety
subjects are generally undersized, and a rickety pelvis is often small ;

Fig. 17. — Diagram of pelvic cavity in small flat
rickety pelvis ; continuous line, normal pelvis ;
dotted line, contracted pelvis. AB, true con-
jugate ; AC, diagonal conjugate ; DC, antero-
posterior diameter of outlet.

Fig. 18.— Scolio-rachitic pelvis.

therefore we have two kinds of rickety pelvis : the flat rickety pelvis, in
which the conjugate is diminished but the transverse measurements either
normal or increased, and the small flat rickety pelvis, in which all the

Fig. 19.— Diagram of brim of scolio-rachitic pelvis ;
continuous line, normal pelvis ; dotted line,
deformed pelvis. BB, sacro-iliac synchondroses ;
E, centre of sacrum in plane of brim ; CC, trans-
verse diameter ; DD, pectineal eminences ; A,
symphysis pubis.

Fig. 20. — Diagram of cavity of scolio-rachitic pel-
vis ; continuous line, normal pelvis ; dotted
line, deformed pelvis. AB, true conjugate ;
AC, diagonal conjugate ; CD, antero-posterior
diameter of outlet.

diameters ate small, but the conjugate is especially contracted. The cases
of extreme pelvic contraction that are met with in England are almost all
pelves either of this kind, or of the one next to be described.

With rickets there often goes lateral curvature of the spine. When
this is so, the pelvis is unsymmetrically deformed. The body weight falls
unduly on the side to which the lumbar convexity looks, and presses the
sacrum towards that size. The lateral mass of the sacrum and the ilium
on the side of the lumbar convexity are compressed, the bony tissue being

224 LABOUE, PEECIPITATE AND PEOLONGED

more compact than normal. The sacrum and the acetabulum are thus
brought nearer together, and the ilio-pectineal line on that side is more
sharply curved. In short, the pelvis is unequally contracted ; the side to
which the lumbar convexity looks being the narrower, because it is the over-
weighted side. The symphysis pubis is pulled over, away from the side to
which the lumbar convexity looks, and the acetabulum on the under-
weighted side, is higher up and further out : because the outward pressure of
the femur acts on this side to greater advantage. This pelvis is called the
scolio-rachilic pelvis.

The Mechanism of Labouk with Contkacted Pelvis. — In describing
the mechanism of labour with contracted pelvis, it must be premised that it
is assumed that the child is of average size and normal conformation. If the
child is too big, the effect on labour is the same as if the pelvis were gener-
ally contracted. If the child is below the average size it may come
through a contracted pelvis without difficulty or altered mechanism.

In considering the slighter kinds of pelvic contraction, the question
arises, how, and where, is the line to be drawn between a normal and a con-
tracted pelvis ? The answer is, that a pelvis which will allow a well-formed
child of average size to pass through it in the usual way, that is, with the
normal mechanism, is a normal pelvis. If the pelvis is in any diameter so
contracted that the child cannot pass in the usual way, but must, by a special
mechanism, adapt itself to the altered diameters of the canal, that pelvis is
contracted. Let us apply this principle. The true conjugate of a normal
pelvis averages about four inches and a quarter : its transverse and oblique
diameters about five inches. The foetal head as it usually presents, lies in
the oblique diameter of the brim, partly flexed, so that the occipito-frontal
diameter, which averages about four inches and three quarters, lies in the
oblique diameter. In the conjugate diameter of the pelvis lies a diameter
of the head running from in front of one parietal eminence to behind the
opposite one, and averaging about four inches. There is then, as has been
pointed out in a former page, no hindrance offered by the bones to the
passage of the foetal head. If the size of the pelvis is so altered that the
head cannot thus enter the pelvis, then the pelvis is contracted. If, for
instance, the conjugate diameter measures only three inches and three
quarters, the diameter running from in front of one parietal eminence to
behind the opposite one, cannot possibly enter the conjugate, and the head
must enter with its long diameter lying transversely, and the bi-temporal
diameter occupying the conjugate. A pelvis with its conjugate diameter
shortened to this extent is therefore contracted ; and if its other diameters
are normal it is called a flat pelvis. Suppose now that the conjugate
diameter of the pelvis only measures four inches, and the oblique and trans-
verse measurements at the brim four inches and a half. It will still be
just possible for the head to enter the pelvis in the oblique diameter ; but
the occipito-frontal diameter will not enter the oblique diameter of the
pelvis. To pass the head must be much flexed, so that the sub-occipito-
frontal measurement may enter the brim. Thus a flat pelvis having a con-
jugate of three inches and three-quarters, and a small round pelvis having
a conjugate of four inches or less, are called contracted ; anything above
these measurements may be considered as normal, only causing difficulty if
the child is large.

The mechanism of labour with contracted pelvis is not merely theoreti-
cally interesting, but is important, because the delivery of a living child
depends upon its entering the pelvis in the most advantageous way ; and
because from observation of the mechanism of the labour, the existence and

LABOUR, PRECIPITATE AND PROLONGED

225

the kind of pelvic contraction can be inferred, the reason of prolongation of
labour ascertained, and indications drawn as to the best treatment. This
statement applies only to the slighter forms of pelvic contraction ; in
deformity so great as to prevent the delivery of a living child, the mechan-
ism is less important.

I shall describe the mechanism of labour with the two common forms of
slight pelvic contraction: the flat and the small round pelvis. The
mechanism of labour with the
flat pelvis depends upon the
degree of contraction, and not
upon whether the pelvis is or
is not rickety.

One feature of the mechan-
ism of labour with the flat
pelvis has already been alluded
to, and the reason for it
explained, viz. that the head
enters the pelvis with its long
diameter in the transverse

diameter Of the pelvis, SO that fig. 21.— Position in which the head enters the brim of the flat
-ifo 'kifaYv<'t->rvY'nl rKoYvia+ov n-v rvno pelvis. A, transverse diameter of pelvis; B, diameter in

its pitemporai ammeter, or one which long diameter of head lies.
a little behind it, is engaged

in the conjugate of the brim. It takes this position because there is not
room in the conjugate for the oblique diameter, from in front of one
parietal eminence to behind the opposite one, which in normal labour
enters the conjugate. A second feature is that in labour with a flat pelvis
the head enters the brim rather more extended than in a normal pelvis ;
so that the finger in the vagina, instead of feeling the smaller fontanelle
low down and the anterior high up and behind, feels both fontanelles at
about the same level. The reason is that the greatest transverse diameter
of the head, the biparietal, is behind the centre of the head. Therefore the
front of the head descends more easily than the back, and thus slight extension
of the head is produced. This extension does not go beyond a certain
degree, because for complete extension to occur the mento-vertical diameter
would have to engage in the brim, and as the transverse measurement of
the pelvis is five inches, and the mento-vertical diameter of the head five
inches and a quarter, this is not possible, unless either the child is very
small, or the head greatly reduced in size by moulding. Under those
conditions it does occasionally occur. The third feature of labour with the
flat pelvis is the occurrence of what is called, from the obstetrician who
described it, the obliquity of NaegeU. This means that the head is so
inclined that its biparietal diameter is oblique in relation to the plane of
the brim. The anterior lying parietal eminence is lower down than the
one which lies behind, and the sagittal suture is nearer the sacral
promontory than the symphysis pubis. The production of this obliquity
depends upon the fact that the axis of the uterus is not a continuation of
that of the pelvic inlet, but lies behind such a line. If no pelvic deformity
be present, the child is driven into the pelvis with exactly the opposite
obliquity, viz. the posterior parietal bone sunk lower into the pelvis than
the anterior, and the sagittal suture rather nearer the pubes than the sacral
promontory. But if the sacral promontory jut forward abnormally, the
descent of the posterior parietal bone is impeded, while that of the anterior
parietal bone is not. Hence the anterior parietal bone is driven down, and
the transverse diameters of the head rotate round the promontory, until the
VOL. vi 15

226 LABOUR, PRECIPITATE AND PROLONGED

anterior lying parietal bone can sink no further into the pelvis, and thus
the obliquity of Xaegele* is produced. This obliquity is not only a
characteristic feature of labour with a flat pelvis, but is a movement

favourable to the passage of the
head through the brim. When
it has come about, the transverse
diameter of the head which has
to pass through the pelvis is a
sub-parietal, super-parietal dia-
meter, which is about a quarter
of an inch less, upon the average,
than the biparietal diameter.
Further, the existence of this
obliquity implies, as a rule, that
the head has been able to engage
with nearly its greatest diameter
in the brim ; for if the pelvis is so
B^aa^wiqpityafHi^^ contracted that the head cannot

engage in it, the situation of the
sagittal suture becomes, so to speak, a matter of accident. Litzmann regarded
the distance of the sagittal suture from the promontory as a guide to the
probable difficulty of delivery ; he drew from his experience the practical
rule that when the sagittal suture ran transversely, and was distant about
three-quarters of an inch from the sacral promontory, forceps delivery was
generally easy.

The three peculiarities just described — transverse position of the long
axis of the head ; increased, but incomplete, extension of the head ; and the
obliquity of NaegeU — are those which characterise the entry of the head
into the brim of a flat pelvis. In a flat pelvis the only difficulty is that
which attends the entry of the head into the brim, and its passage through
it. When once the head has passed the brim all difficulty is at an end.
The head entering the brim with the Naegele obliquity, the anterior
parietal bone becomes fixed against the symphysis pubis, and then the
posterior lying parietal bone gradually scrapes past the sacral promontory.
If it is pulled through with forceps, the operator will feel it suddenly slip
past the promontory, and will find that then it is easily pulled further.
The passage of the promontory is generally — always in difficult cases —
made possible by alteration in the shape of the head. The posterior lying
parietal bone becomes flattened, and driven under the anterior, and also
under the parietal and occipital bones. The line along which the head was
opposed to the most projecting point of the promontory is often traceable,
either by redness and ecchymosis of the skin, or by a groove in the bone.
The usual situation of such a groove is along the anterior border of the
parietal bone. If the head is soft and has been allowed to remain long
stationary at the brim, a deep spoon-shaped dint may be formed at the point
where the head rested against the promontory. Lastly, it must be
mentioned that the weakest part of the foetal head is the anterior inferior
angle of the parietal bone ; and that where pressure upon, and overriding
of bones, is great at this point, such force may lead to laceration of vessels,
meningeal hsemorrhage, and death of the child. Cases are met with in
which the child is known to be alive, and is delivered by short but strong
pulling with forceps, but dead. In such cases meningeal hsemorrhage is
the usual cause of death.

When with a flat pelvis the child is delivered by turning, the after-

LABOUE, PEECIPTTATE AND PEOLONGED

227

coming head passes the brim by a mechanism exactly analogous to that which
obtains when the head comes first. The head lies transversely, the biparietal
diameter being at one side of the promontory. If there is much resistance
to the passage of the head, it becomes partly extended. When the head is
pulled upon, the anterior part of the head descends first. Then the pro-
jecting sacral promontory holds back the posterior lying parietal bone, and
the anterior side of the head descends first, rotating upon the sacral
promontory as a centre ; and then, lastly, the posterior lying parietal bone
slips down, often being grooved or marked in the same way as if the head
had come first. In labour with a flat pelvis, a large caput succedaneum is
unusual, nor is there often oedema of the vagina or vulva. Premature
rupture of the membranes is common with flat pelves, from causes and
with results which are described elsewhere. Abnormal presentations of
all kinds are more frequent with flat pelves than with normal pelves. Their
treatment is described elsewhere. I would only here say that when a

Fig. 23. — Showing mark made by promon-
tory in delivery of the after - coming
head. (After Kiistner.)

Fig. 24. — Showing change in
shape of head produced by
traction with base in ad-
vance. (See also Fig. 52,
p. 250.)

face presentation is met with in a flat pelvis, I think the best treatment is
podalic version.

The mechanism of labour with the small round pelvis is in one point
in broad contrast with that of labour with the flat pelvis. In the flat
pelvis all the difficulty is at the brim. In the small round pelvis there is
difficulty throughout the whole pelvic canal. The difficulty is to get the
head into the flat pelvis, to get it through the small round pelvis. In the
small round pelvis there is not the liability to abnormal presentation, nor
to premature rupture of the membranes, which the flat pelvis brings with it ;
for the head readily enters the pelvis, engages in it, and shuts off the fore-
waters from the general intra-uterine pressure.

In the small round pelvis the head can only get through it in a position
of extreme flexion, so that the suboccipito-frontal diameter may be the largest
which passes through the pelvic cavity. Hence the posterior fontanelle is
lower down and nearer the middle of the pelvis than usual ; and flexion
occurs earlier than in normal labours, because it is produced as soon as
the head sinks into the pelvis. The head enters the pelvis with its lono-
diameter in the usual oblique diameter of the pelvis, because at the brim
this diameter is the longest. At the pelvic outlet the antero-posterior
diameter is the longest ; and therefore the head, as soon as it gets into the
pelvic outlet, turns so that its long diameter occupies the antero-posterior
diameter of the outlet. In normal labour a similar turn takes place, but

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LABOUE, PKECIPITATE AND PEOLONGED

here the turn is caused by the soft parts, not by the bones, and it occurs
not till the head is past the pelvic outlet and is stretching the
perineum. This early rotation is one of the features of labour with the
small round pelvis. In labour with a normal pelvis the head advances
during each pain, and recedes in the intervals between the pains ; and after
the soft parts have turned its long diameter till it lies antero-posteriorly,
there is nothing to turn it into any other position. But if the pelvis is of
the small round class, and the head is turned forwards by the bones, when
it recedes between the pains its position is still governed by the bones ; and
it therefore turns back again, so that its long diameter may still lie in the
longest diameter of the pelvis, which, after the recession of the head, is the
oblique. This variability of position is very characteristic of the small
round pelvis. "When the passage of the head through the pelvis is difficult,
either because the pelvis is a small round one, or because the child is very
large, the difficulty is not, as in the flat pelvis, at the brim only, and there
only in the conjugate diameter, bounded by the sacral promontory and

Pig. 25. — Pressure marks on head after
labour with flat pelvis.

Fig. 26. — Pressure marks on head after
a labour with small round pelvis.

the symphysis pubis, but it is throughout the whole pelvic canal, and the
head is pressed upon all round by the pelvic canal. Hence where the head
is so pressed upon — the girdle of contact — the return of blood from the
part of the scalp which is presenting is impeded. Hence early and ex-
tensive oedema of this part — in other words, a large caput succedaneum.
The return of blood is also impeded from the lower part of the vagina and
vulva, and hence ceclema of the vagina and labia. But as the blood from
these latter parts can return to the heart by other channels than those
pressed on by the advancing head, the oedema of the labia is not so great,
and is later in forming than the caput succedaneum. The swelling
of the labia is visible : the vagina is felt to be dry and swollen. With the
small round pelvis the obliquity of Naegele is absent ; for the head is not
hindered in descent by the sacral promontory ; it enters the pelvis without
difficulty, but meets with hindrance to its passage through it. The
head often enters the small round pelvis with posterior obliquity ; but I
know not that the existence of this obliquity materially affects the course
of labour. The passage of the head through the small round pelvis is
helped by moulding of the head. The head being pressed upon all round,
there is a general compression of the head mainly affecting the sub-
occipito-frontal measurement, and elongation of its long diameter, the

LABOUE, PEECIPITATE AND l'EOLONGED 229

vertico-mental. Grooves and dints in the bones are rare. There is some-
times a red stripe on the skin where it passed the promontory ; this runs
from the parietal bone downwards and forwards towards the jaw or eye.
At birth the occipital and frontal bones are commonly pressed under the
parietal bones, and the posterior lying parietal bone underneath the anterior ;
but this overriding is effaced within a few days. Lateral asymmetry of
the skull is a frequent result of prolonged labour, both with the small round
pelvis and with the flat pelvis ; but I think it more common and more
marked with the small round pelvis. The reason is in the projection of the
sacral promontory. As the head descends into the small round pelvis the
half of the head that lies behind meets with more resistance, and hence gets
pushed forwards (speaking with reference to the head). In a flat pelvis the
resistance offered by the promontory to the descent of the biparietal
diameter leads to the displacement backwards of the half of the head that
lay behind. Eupture of the uterus occurs less frequently with the small
round pelvis than with the flat pelvis ; because in the former, if the head
nips the cervix so tightly as to prevent it rising, such pressure is exerted
all round the pelvis, and so quickly produces oedema of the vagina and
vulva that the need for prompt treatment is soon apparent.

In the foregoing pages I have described the common kinds of slight
pelvic deformity and the mechanism of labour occurring with them. From
the point of view of the practical obstetrician these are more important
than the greatly deformed pelves, because (1) they are common, while
great deformity is rare ; (2) by recognising them early and managing labour
properly, a living child can often be delivered, and the mother always
saved injury from protracted labour ; their accurate diagnosis requires full
knowledge and careful examination ; and the decision as to the best treat-
ment is often difficult. Great pelvic deformity is, as it were, forced upon
the notice of the doctor, and when discovered there is no doubt as to the
proper treatment. (3) "When the head cannot pass the pelvis, or cannot
pass it without being first crushed, the mechanism of its passage is not
important.

Eaeer Forms

I now describe the rarer forms of pelvic contraction, and I shall
point out the important features special to labour with each.

The flat, the small round, and the different kinds of rickety pelvis are
the common kinds of contracted pelvis — those which any one who has a
large midwifery experience is sure to meet. Some of the rare forms are
interesting on account of the light they throw on the development of the
pelvis.

The funnel-shaped pelvis means a pelvis without disease of the bones,
in which the transverse dimensions lessen in size from above downwards.
Only two specimens of this deformity had, up to 1889, been described.
The accounts of clinical observers would make one think that this pelvis
must be commoner in practice than it is in museums. But the difficulty in
diagnosis is so great — for we have no means of accurately measuring during
life the transverse diameters of the pelvis — that clinical accounts can only
be accepted when it is evident that the reporter has been aware of the great
probability of error. If labour is lingering, and the cause seems to be that
the advance of the head is blocked by a narrow pelvic outlet, the treatment
is to help delivery by pulling with forceps. If this fail, cephalotripsy is
the only resource. After delivery the pelvis should be measured, and the

230

LABOUK, PEECIPITATE AND PKOLONGED

patient told to come for advice, should a subsequent pregnancy occur, not
later than the seventh month.

The oblique pelvis of NaegeU is a rare pelvis, the shape of which is
altered by a defect in ossification. The defect consists in imperfect develop-

a*' c

Fig. 27. — Diagram of cavity of funnel-shaped pelvis Fig. 2S. — Diagram ot cavity of funnel-shaped pelvis in
in sagittal plane ; continuous line, normal coronal plane ; continuous line, normal pelvis ; dotted
pelvis ; dotted line, funnel-shaped pelvis ; AB, line, funnel-shaped pelvis. AA, iliac crests ; BB, trans-
true conjugate ; AC, diagonal conjugate' CD, verse diameter of brim CC, inner surface of tubera
antero-posterior diameter of outlet. ischii

ment, on one side only, of the lateral part of the sacrum and the adjacent
part of the ilium, and ossification of the sacro-iliac synchondrosis on that
side. We know nothing as to the cause or date of the developmental defect.

Fig. 29.— Obliquely contracted pelvis of Naegele.

Fig. 30.— Diagram of the brim of Fig. 29 ; con-
tinuous line, normal pelvis ; dotted line, oblique
pelvis. BB, sacrum ; CC, acetabulo ; A, sym-
physis pubis.

Its effect is to bring the acetabulum, on the affected side, nearer
the middle line than in the normal pelvis, and nearer the middle
line than the acetabulum on the opposite side. I have already pointed out
that the femora press the acetabula upwards and outwards. The farther
out are the acetabula, the more effective is the outward thrust. Hence on
the diseased side the thrust of the femur is mainly upwards, and but little
outwards. On the sound side the outward pressure acts with greater
advantage and the upward pressure with less. Hence on the sound side the
acetabulum is pushed farther outwards than usual ; the wing of the ilium
looks more forwards and less inwards ; and the symphysis pubis is pulled
towards the sound side.

LABOUE, PKECIPITATE AND PROLONGED

231

There is no deformity in any other part of the body. There is no
history of injury, disease, or lameness, and the patient presents, when
clothed, no peculiarity of aspect or gait. Hence the existence of this pelvis
is not suspected until it is discovered on obstetrical examination during
pregnancy or labour.

The diagnosis of the oblique pelvis of Naegele is to be made (1) by
feeling the outline of the iliac crests, perceiving their asymmetry and the
displacement of the symphysis pubis ; (2) by measuring with callipers the
distance between the posterior superior iliac spine of one side and the
anterior superior iliac spine of the opposite side. These measurements on
the two sides will be unequal, that which is taken from the diseased side
behind being the greater ; (3) by exploring the pelvic cavity with two fingers
in the vagina, and noting its shape.

The important point obstetrically about the Naegele pelvis is the
diminution in the oblique diameter on the diseased side. If labour is to
terminate naturally the head must be small, and must enter the pelvis with
the occiput towards the obturator foramen on the sound side. As these
conditions are not always complied with, the infantile mortality is about
25 per cent.

If consulted during pregnancy by a patient who is found to have an
oblique Naegele pelvis, the relative sizes of the head and the pelvis should be
estimated by abdominal palpation, and labour induced before the head has
got so large that it cannot be pressed into the brim. If consulted for the
first time when labour is in progress the question is, Can the head enter the
brim or not ? If its equator is engaged in the pelvis, or can be pressed down
into it, there is no need for interference. If the head cannot enter the
brim the choice lies between craniotomy and Csesarean section — the former
being the safer for the mother, the latter preserving the child. Csesarean
section should not be chosen if the patient has been long in labour. Turn-
ing gives no advantage. Symphysiotomy, owing to the ankylosis of one
sacro-iliac synchondrosis, will not enlarge a Naegele pelvis as much as it
does a normal pelvis.

The transversely contracted pelvis of Booert is that produced by want of
development of the lateral masses of the sacrum and ankylosis of the
sacro-iliac synchondrosis on both sides. The result is that the pelvis grows
not in breadth as it should do. Hence the acetabula are nearer the middle
line, and the outward pressure of the
femora upon them is exerted to less
advantage; the acetabula are driven
more upwards and less outwards.
The ossa innominata are less curved ;
the parts between the acetabula and
the sacrum are compressed, shortened,
and thickened. Hence the conjugate
diameter is shortened as well as the
transverse, though not to the same
high degree.

The diagnosis of the transversely
contracted pelvis of Robert is made by
the transverse measurements of the
pelvis : the intercristal, anterior and
posterior interspinous, and bitrochanteric.
With the finger in the vagina, the closeness of the ischial tuberosities
and the narrowness of the pubic arch will be perceived. This pelvis is

Fig. 31. — Transversely contracted pelvis of Robert.

232

LABOUK, PKECIPITATE AND PEOLONGED

usually so small that the only way of delivering its owner of a living child
is by Csesarean section.

The kyphotic pelvis is that which is produced when angular curvature of
the spine occurs low down. When such curvature is high up it is compen-
sated for by lordosis of the lumbar spine. But when it is so low down that
change in the curve of the spine below it cannot compensate its effect, then
a change in the inclination of the pelvis takes place, and this change in
inclination gradually produces change in shape.

In the diagram (Fig. 32), CG represents the upper limb of the kyphosis.
The weight of the upper part of the body acts along the line CGI.
GP represents the lower limb of the angle ; P is the sacral promontory ;

Fig. 32. — Diagram illustrating the
production of kyphotic pelvis ;
G, angle of kyphosis ; PP,
promontory of sacrum ; CC,
tip of sacrum.

Fig. 33. — Kyphotic pelvis. (After Barbour.;

PC the sacrum. The effect of the pressure acting along the line CGI is
to drive the angle of the kyphosis downwards and backwards, and this
movement through the traction on the lower limb of the angle pulls
the sacral promontory upwards and backwards. The inclination of the
pelvic brim is changed, so that if its shape were unaltered its plane
would form a less angle with the horizon. But the continuous pull on the
promontory in the course of years makes the curve of the sacrum from above
downwards less, raises the promontory above the level of the pelvic brim,
and lengthens the distance between the sacral promontory and the
symphysis pubis. As in rickets the bodies of the sacral vertebrae are the
parts most pushed down, so in the kyphotic pelvis the bodies are the parts
most pulled up — the lateral parts of the sacrum being in each case bound to
the iliac bones. Hence the concavity of the sacrum from side to side is in-
creased in the kyphotic pelvis. The traction on the upper part of the
sacrum leads to a rotation of the bone about a horizontal axis, so that while

LABOUK, PKECIPITATE AND PROLONGED

233

its base is displaced backwards its apex is moved forwards, thus lessening
the antero-posterior diameter of the outlet. The movement upwards' and
backwards of the base of the sacrum pulls on the ilium, and makes the curve
of the os innominatum not so sharp. The lessened inclination of the pelvic
brim to the horizon causes increased strain on the ilio-femoral ligament.
These pull the anterior inferior iliac spines down and out, and so rotate the
ossa innominata about an axis running from before backwards. This rota-
tion widens the space between the iliac crests and approximates the ischia.
Hence the main changes from an obstetrical point of view are lengthening
of the antero-posterior diameter at the brim, slight widening of the trans-
verse measurements at the brim, considerable narrowing of the transverse
measurements at the outlet. How marked these changes are depends upon
how low down the kyphosis is.

Kyphosis of the spine is a common disease ; but a well-marked

Pio. 34. — Diagram of cavity of kyphotic pelvis in
sagittal plane ; continuous line, normal pelvis ;
dotted line, deformed pelvis. AB, true conjugate ;
AC, diagonal conjugate ; CD, antero - posterior
diameter of outlet.

Fig. 35. — Diagram of brim of kyphotic pelvis ;
continuous line, normal pelvis ; dotted line,
kyphotic pelvis. A, symphysis ; BB, sacro-
iliac synchondroses ; CC, transverse diameter ;
DD, ilio - pectineal eminences; middle of
sacrum in plane of brim.

kyphotic pelvis is not common, because for its production it is necessary
that the disease should begin early in life, and be situated low down.

The diagnosis is easy because the condition is suggested by the patient's
short stature and crooked back. When the curvature of the spine has been
discovered the pelvic outlet should be measured. Those of the brim are
difficult to take, and as if altered they are increased, it is not important to
make them. The ease or difficulty of labour depends upon how much the
outlet is contracted.

Alike in head, breech, and transverse presentations, dorso-posterior posi-
tions are more frequent with kyphotic than with normal pelves. The
abdominal concavity of the child adapts itself to the lumbar convexity of
the normal spine. The dorsal convexity of the child fits the concavity
which kyphosis produces in the lumbar spine. If the deformity is not so
great as to make delivery impossible, and the head presents with the
occiput forwards, the only difference the kyphotic pelvis produces is that
the increasing approximation of the sides of the pelvis as the head moves
down makes the occiput turn forwards earlier than it does in normal labour.

234

LABOUE, PEECIPITATE AND PEOLONGED

When the occiput is behind and the deformity great, the narrowing of the
front of the pelvis often prevents the occiput from turning forwards, and
the head, if it be small enough, is born through the space bounded by the
ischia in front and the coccyx behind, the sagittal suture lying in an oblique
diameter.

The treatment of labour with a kyphotic pelvis should be guided by the
same principles as in other forms of contracted pelvis. The index for treat-
ment is the transverse measurement at the outlet. If this is so contracted
that a living child cannot be drawn through it, early Cesarean section should
be done. Symphysiotomy is not here of much use, because the separation of
the ischia which it allows is but slight. If the transverse at the outlet ex-
ceed three inches, and the child is of not more than average size, it can

Fig. 37. — Diagram of brim of Fig. 36 ; continuous line,
normal pelvis ; dotted line, deformed pelvis. BB,
sacro-iliac synchondrosis ; E, centre of sacrum in
plane of brim ; CC, transverse diameter ; DD,
pectineal eminences ; A, symphysis pubis.

Fig. 36.— Kypho-scolio-rachitic pelvis. (After Leopold.)

probably be born alive, and if the pains are so weak that help is needed it
should be given with forceps. Turning is no advantage.

The . Kypho-scolio-rachitic Pelvis. — This is the pelvis produced when
caries of the spine low down occurs in a rickety subject who has a lateral
curvature of the spine. The rickety pelvis and the kyphotic pelvis are
almost the exact opposite of each other. This pelvis is as it were a com-
promise between them. As in the kyphotic pelvis, the sacral promon-
tory is drawn up and back, and the tip tilted forwards ; but the sacrum
presents the rickety convexity from side to side, and the thickening of the
epiphyseal lines. The general shape of the pelvis is funnel-shaped, like that
of the kyphotic pelvis. The antero-posterior diameter of the brim is
lengthened, and the transverse slightly diminished, and the ilio-pectineal line
is longer and straighter. The transverse diameter at the outlet is diminished.
The scoliosis leads to asymmetry of the pelvis. The sacrum is pushed

LABOUK, PEECIP1TATE AND PKOLONGED

235

Fig. 38. — Diagram of cavity of Fig. 36 ; continuous
line, normal pelvis ; clotted line, deformed
pelvis. AB, true conjugate ; AC, diagonal
conjugate ; CD, antero-posterior diameter of
outlet.

towards the side of the lumbar convexity, and therefore the sacro-cotyloid

diameter on that side is shortened. On the opposite side the upward and

outward pressure of the femur acts to

greater advantage, and therefore the

symphysis pubis is pulled over to that

side. The degree of these changes

depends upon the extent and situation

of the spinal curvatures producing

them. According to whether the

kyphosis or the scoliosis is the more

marked, and whether the kyphosis

is low down or not, the pelvis will

approximate to either the scoliotic or

the kyphotic type. The diagnosis of

this form of pelvis will be suggested

by the spinal curvatures present, and

will be completed by measurement of

the pelvis. According to whether the

pelvis approaches more nearly the

kyphotic or the rachitic type, so the

treatment must be guided by the

principles governing treatment in the kyphotic and the rachitic pelves

respectively.

The Osteomalacic Pelvis. — In this pelvis, as in the rickety pelvis, the
deformity is due to softening of the bones, so that they yield to pressure
and pulling. The conditions of its production differ from those of the
rickety pelvis, in that it occurs in adults, in whom the muscles are stronger
and more used than in rickety children ; and that the softening is greater
than in rickets. The consequence is that muscular action affects the

shape of the pelvis more with
osteomalacia than it does with
rickets. The muscles pull out the
pubes and ischia, and pull in the
head of the femur. As soon as
the head of the femur is within
the line passing from the sacrum
to the feet, the femoral pressure
reacting to the body weight
becomes upwards and inwards,
instead of upwards and outwards ;
and then it combines with the
action of the muscles to crumple
in the acetabula. Hence the
pelvis becomes " rostrate," the two
pubic bones running nearly parallel so as to project forwards like a beak.
The acetabula are approximated to the sacro-iliac synchondrosis, so that the
pelvic canal becomes somewhat the shape of a Y. The sacrum yields to the
body weight, and is pressed down, as in rickets, but more : the promontory is
often so sunken that the fifth or even the fourth lumbar vertebra may come
to lie in the plane of the pelvic brim. As in rickets, and for the same reason,
the sacrum becomes convex from side to side, but more so ; the curve is so
great as to appreciably narrow the bone. While the sacral promontory is
pushed down the tip of sacrum is prevented from moving back by the sacro-
sciatic ligaments ; hence the sacrum becomes sharply curved from above

Fig. 39.— Osteomalacic pelvis.

236 LABOUR, PRECIPITATE AND PROLONGED

downwards. The pull of the sacrum upon the ilium at the synchondrosis,
combined with the upward and inward pressure of the femur upon the
acetabulum, crumples up the ilium until the iliac fossa becomes like a
gutter. The sacrum and ilium may get separated at the synchondrosis.
When the disease is advanced the bones become so soft that the patient
cannot stand or walk, but lies or crouches in various attitudes. Hence
different distributions of pressure in different patients, and corresponding
minor differences in the shape of different osteomalacic pelves. Although
all osteomalacic pelves conform to the same general type, yet they do not
exactly resemble each the others, as do pelves of the Naegele or the Robert
type.

Osteomalacia begins during pregnancy or lactation. There is severe
pain, especially on movement. The spine and ribs are soft as well as the
pelvis ; from this they become bent, and the capacity of the chest is
diminished. Hence the lungs cannot properly expand, and the patient
suffers from cough, shortness of breath, suffocative attacks, and muscular
cramp. There is an excessive excretion of phosphates in the urine. When
the disease has been cured this ceases. The cure of this disease is by re-
moval of the ovaries. We know not how this acts, but the fact is
established. The disease is rare in England ; endemic in certain parts of
Europe.

The diagnostic points of osteomalacia while it is progressing are (a) the
tenderness, (&) the softness of the bones. The pelvic deformity is so extreme
that measurement is not needed to detect it.

Obstetrically the osteomalacic pelvis is unique among contracted pelves
in this, that it has been found possible, so soft may the bones be, to force
the pelvis open with the hand to a degree sufficient to allow a living child
to pass. But it is hardly worth while to do this, because the patient must,
for her cure, have her abdomen opened. The best treatment is to perform
Csesarean section, and then remove the body of the uterus and the ovaries.
This done, the patient's pains will cease, the phosphates in her urine
diminish, and the bones will get hard. The deformity will never be
removed.

There is a rare form of contracted pelvis known as the pseudo -osteo-
malacic rickety pelvis. The shape of this pelvis is like that of the osteo-
malacic pelvis (only not to the same extreme degree), that is, the acetabula
are crumpled in so as to make the pelvic cavity Y-shaped, instead of being

pressed up and out, so as to
^l^^yitk widen the pelvis. But the

deformity is due to rickets in
early life ; osteomalacia is
not present. The deformity
not being so great as in osteo-
malacia, the iliac crests are
not bent, but are splayed
out as in the flat, rickety
pelvis. The explanation of
the production of this shape
of pelvis in a few exceptional
cases of rickets is, that it

Fig. 40. — Pseudo-osteomalacic rickety pelvis. (Alter Naegele.) . , , i -i • -i j

is due to very bad rickets,
making the bones very soft, and preventing the child from standing
or walking. The consequence is, that the upward and outward
pressure of the femora, which is exerted all the time that the

LABOUE, PRECIPITATE AND PROLONGED

237

patient is standing or walking, and which in ordinary rickets pushes the
acetabula up and out, widening the pelvis, is in these bad cases absent.
But whenever the patient lies on her side the pressure on the trochanter
drives in the head of the femur, and whenever she moves her thighs the
muscles passing from the pelvis to the trochanter pull in the head of the
femur. Hence the acetabula become crumpled in. The deformity becomes
not extreme, because by the time the patient is able to walk the disease is
cured, and the bones have got hard, and then they yield not further to the
upward pressure of the femora. In conformity with this view is the fact,
that one of the few possessors of pelves of this kind whose history is known
(a case described by Naegele) did not attempt to walk till she was seven
years old.

Obstetrically these cases resemble the osteomalacic pelvis, except that as
the bones are hard it is not possible to force them apart with the hand.

Spondylolisthesis. — This is the pelvic deformity produced by the
slipping forward of the last lumbar vertebra upon the sacrum. It is
produced by the coincidence of two conditions : (1) a malformation, (2) a

Fig. 41. — Alumbar vertebra showing the defect in ossifi-
cation upon which spondylolisthesis depends.

Fig. 42.— Spondylolisthesis. (After Kilian.)

strain. The malformation consists in defective ossification of the last
lumbar vertebra, so that between the upper and lower articular processes
there is a gap in the bony ring filled with cartilage or fibrous tissue. This
bony defect is common, but spondylolisthesis is rare. The bony defect,
therefore, is not by itself capable of producing the deformity. But it
weakens the bony ring and thus makes it yield to strain. The strain may
be gradual, as from long-continued heavy labour, or sudden, as from
accidental violence. When from either cause the body of the last lumbar
vertebra is driven down, the bony ring gives way at this weak spot ; the
body of the vertebra, with its upper articular processes, slips forward ; the
inferior articular processes remain in their place. One case has been
described in which it was due to fracture, or rather separation, of the
pedicles of lumbar vertebrse in a girl of 16. But obviously a defect which
is common is more likely to be a usual cause of the disease than a defect
which is rare. It has been supposed that the deformity may arise from
fracture of a properly ossified vertebra; but this has not been demonstrated ;
and it is obvious that a bone with the defect mentioned above is more likely
to give way than a well-ossified one. It has been said also to be due to
fracture of the sacral articular processes, letting the whole of the last
lumbar vertebra slide forwards ; but this has not been proved.

238

LABOUE, PEECIPITATE AND PEOLONGED

When the dislocation has once occurred secondary changes in the
bones concerned come about, (a) The canal of the last lumbar vertebra is
enlarged from before backwards, (b) The body of the vertebra, in its new-
position, is not supported in front, and hence it becomes bent, its anterior
part forming an angle, opening downwards, with its posterior, (c) The
hinder part of the body of the vertebra is compressed between the fourth
lumbar vertebra and the sacrum, so that it becomes the shape of a blunt
wedge, the-base of the wedge being in front, (d) The slipping forward of

Fig. 43.— Early stage of spondylolisthesis. (After Targett.)

the last lumbar vertebra involves strain on and damage to the inter-
vertebral substance between it and the first sacral vertebra, (e) The result
is the growth of bone in the intervertebral substance, and between the
displaced vertebra and the last sacral vertebra. This ossification tends to
prevent further dislocation, and is therefore a conservative change. The
body weight, transmitted through the spine, instead of falling on the
top of the sacrum, falls on its front edge, and thus pushes the top of
the sacrum backwards. This tends to narrow from before backwards the
canal of the sacrum. The pushing of the sacrum back separates the
posterior superior iliac spines (see Fig. 43). There is extreme lordosis of the
lumbar spine, so that the front edge of the bodies of the vertebra are farther

LABOUK, PEECIP1TATE AND PROLONGED 239

apart than they ought to be, while the neural arches are pressed together.
This pressure may lead to bony outgrowths, ossification of the ligaments,
and finally synostosis. The inclination of the pelvis to the horizon is
diminished. This throws increased strain on the ilio-femoral ligaments.
The pull of these ligaments rotates each os innominatum about an antero-
posterior axis, so that the upper part of the bone is turned outwards, the
lower inwards. Hence, as in the kyphotic pelvis, the transverse diameter
at the brim is widened, that at the outlet narrowed.

The changes described above are seen in different degrees in different
pelves. The ossific defect may be on one side only, and then the vertebra
will slip down on that side more, and the deformity produced will be
asymmetrical. But the disease is so rare that it is not worth while to
dilate upon the differences in degree and in symmetry.

In the diagnosis of spondylolisthesis investigation has to be made along
three lines. First, the history. This will be of some violence or strain,
leading to a long illness, attended with pain in the lower part of the back,
and severe enough to keep the patient in bed. The usual date of this
illness is from the fifteenth to the eighteenth year. Second, the shape of
the body. The patient is short, and this is seen to be due to shortening of
the lumbar spine. The distance between the ribs and the pelvis is
diminished ; the ribs may even be sunk into the false pelvis. This makes
conspicuous the distance between the wings of the ilia. The posterior
superior iliac spines are farther apart than usual. The back of the sacrum
is plainly felt. From the less inclination of the pelvis the external
genitals look more forward and less downwards than usual. The patient
walks with short steps, and with the feet slightly inverted, so that the
marks made by the feet are wanting in breadth. Third, vaginal ex-
amination. The displaced lumbar vertebra is felt narrowing the brim.
It is distinguished from the projecting promontory of a rickety pelvis by
the fact that at its sides nothing like the lateral masses of the sacrum can
be felt ; and also that by external examination the sacrum can be felt not
to be displaced. A distinct angle between the displaced vertebra and the
sacrum cannot be felt, because this angle is filled up with new bone. As
in the kyphotic pelvis, the distance between the ischial tuberosities is
lessened, and the tip of the coccyx extends farther forwards than usual.

"When caries of the last lumbar vertebra and top of the sacrum has
been present, the angular curvature produced leads to the lumbar vertebrae
overhanging the brim of the pelvis somewhat as the last lumbar vertebra
does in spondylolisthesis. This deformity is called spondylizema. This
and spondylolisthesis have been classed together under the common name
of the pelvis obtecta.

The treatment of labour with spondylolisthesis depends upon the
length of the obstetrical conjugate. It is possible that cases may be met
with in which deformity is so slight that delivery can be effected by forceps
or turning ; but in most — in all which deserve the term pelvis obtecta —
Csesarean section is the proper treatment.

The split Pelvis. — In this deformity the symphysis pubis is absent.
The two halves of the pelvis not being bound together in front, the upward
and outward pressure of the femora forces them widely apart, so that there
is a wide gap between the pubic bones, which are united only by some
fibrous tissue. The ossa innominata are rotated about an axis parallel
with the axis of the pelvic brim, so that the posterior iliac spines approach
one another. This shortens the distance spanned by the ligaments which
suspend the sacrum from the ossa innominata, and the sacrum is therefore

240

LABOUE, PEECIPITATE AND PEOLONGED

Fig. 44.— Split pelvis.

allowed to slip forwards and downwards. This approach to one another of
the posterior iliac spines, and sinking downwards of the sacrum, reaches in

extreme cases such a degree that
it looks as if there was a canal
behind the sacrum instead of
in front of it ; and this has
caused the name "inverted
pelvis" to be applied to it.
The general shape of the pelvic
canal is that of an extreme type
of rickety pelvis, but with a
large gap in front. It is almost
always associated with extro-
version of the bladder; and
from the disgusting nature of
this deformity pregnancy with
this pelvis is rare. Only seven
cases have been recorded. In
the management of labour with this deformity the choice is between
turning and Caesarean section, according to the size of the child and the
antero-posterior measurements of the pelvis.

There are two causes which may deform the pelvis, fracture of the
pelvic bones and hip disease, in which the deformity cannot be said to
conform to any type. In the former the nature of the injury and the
position of the fragments during union regulate the shape of the pelvis.
In the latter it depends upon the extent of the disease, the age of the
patient, and the presence or absence of dislocation. All that can be said is
that old hip disease generally in some way modifies the shape of the pelvis.
There are other kinds of pelvic deformity, for instance that due to con-
genital dislocation of the femora, which narrow not the pelvis, and therefore
obstruct not labour. A pelvis called the foetal or lying-down pelvis has
been described ; but no case of pregnancy with it has yet been known.
These pelves are obstetrically not important, although from other points of
"view they may be very interesting.

I shall now describe more in detail the methods of measuring the
pelvis, and the application of such measurements to the management of
labour.

Pelvimetry

The existence and degree of pelvic contraction are found out during life
by 'pelvimetry. There are two kinds of pelvimetry, external and internal.

I. External pelvimetry is done with callipers, the best for the purpose being
those sold under the name of Matthews Duncan's. The essential features
of the instrument are that the points should be blunt, so that they hurt not
the patient, that the limbs be large enough and curved enough to embrace
half the pelvis, and that a measuring scale be attached so that the distance
between the points can be read off without trouble. The external measure-
ments usually and easily taken are three : — (1) The anterior inter spinous,
which is the distance between the anterior superior iliac spines. It
may be measured either by putting the points of the callipers outside each
bony point, or by applying the thumbs to the inner side of the spines, and
by then feeling that the points of the callipers are level with the inner
borders of the iliac spines. I think the latter is the more accurate method.
The method adopted makes a difference of an inch or more in the measure-

LABOUB, PEECIPITATE AND PROLONGED

241

ment obtained, the distance between the inner borders being less than that
between the outer. It averages about ten inches, but varies from eight to
twelve inches. (2) The intercristal, or the distance between the most
distant points of the iliac crests. This is obtained by putting the points of
the callipers on the outside of the crests and moving them about until the
greatest separation between them is reached. This measurement averages
about eleven inches, but varies from ten to fourteen inches. These measure-
ments have but little practical importance, and would not be worth making
if making them caused discomfort to the patient. They show roughly the

Fig. 45. — Duncan's callipers.

width of the pelvis, but their relation to the internal transverse measure-
ments varies so much that no inference can be drawn unless the measure-
ments differ extremely from the normal. The due proportion between the
two measurements shows a normal curve of the iliac crests. An altered
relation, so that the interspinous is as great as the intercristal, shows that
the ilia look more forward than they should do and that the pelvis is
flattened. But no inference can be drawn from an altered proportion so
slight as to need measurement for its detection. (3) The external conjugate,
which is measured from the depression below the last lumbar spine to the
most distant point on the front of the symphysis pubis. The last lumbar
spine is usually to be found about an inch above the line joining the
posterior superior iliac spines. This diameter averages in thin women
about seven and a half inches. It was at one time supposed that there
was a constant relation between the external and the internal conjugate,
VOL. vi 16

242 LABOUK, PEECIPITATE AND PKOLONGED

that by deducting three inches from the former the length of the latter
might be ascertained. This has been carefully tested and found not to hold
good. The difference between the two conjugates varies from three to four
and a half inches. Hence an external conjugate of seven and a half inches
is no guarantee that the pelvis is not contracted. On the other hand, when
the internal measurements are normal, if the patient be thin and her bones
slender, the external conjugate may be slightly less than seven and a half
inches. But if the external conjugate is less than seven inches it is certain
that the internal conjugate is contracted.

Some other external measurements are not so easily made. When the
patient is not pregnant, and if she is not too fat and will relax her abdominal
walls, the true conjugate can be measured by Hardies method. This consists
in depressing the anterior abdominal wall until the promontory is felt, and
then measuring the distance from the promontory to the top of the pubes.
This cannot be done accurately, for the posterior end of the measurement is
not the promontory, but the promontory plus the thickness of the abdominal
wall, and the anterior end of the measurement, the top of the symphysis, is
not the nearest point to the promontory. It is thought that in women
with abdominal walls of ordinary thickness these two inaccuracies about
neutralise one another. This may be so, but the existence of these inaccuracies
prevents this mode of measurement from being more than an approximation.
Still, it is in some cases a useful approximation, and can be used as a
" control experiment " to measurements otherwise obtained.

In some pelves, the kyphotic and the funnel-shaped pelvis, it is important
to measure the transverse diameter at the outlet. This is difficult to do,
because the bony points, the distance between which we want to know, viz.
the tubera ischiorum, are covered with such a thickness of soft parts that it
is impossible to get any measuring instrument directly on to them. The best
way of doing it, in my opinion, is to make the patient kneel on her elbows
and knees, and then, feeling the position of the ischia with the fingers, to
mark their outline on the skin of the buttocks, and then measure the
distance between the markings. It is more difficult than would be expected
to mark out accurately the position of bones which lie so deep, but it is
obvious that such error as may occur in deliberately marking out the outline
of the bones is more likely to happen if the measurement is made, or attempted
to be made, without first marking the skin.

In cases of oblique deformity of the pelvis measurements should be
taken from the posterior superior iliac spine on each side to the anterior
superior iliac spine of the opposite side, and from the hollow below the last
lumbar spine to the anterior superior spine on each side. This will enable
the amount of deformity to be estimated. But a degree of obliquity that
cannot be detected without this measurement is not of great importance.

The distance between the 'posterior superior iliac spines may be measured.
It is usually about one-third of the distance between the anterior superior
iliac spines. In the fiat pelvis the posterior spines are abnormally approxi-
mated and the anterior abnormally separated, and therefore the difference
between the posterior and anterior interspinous measurement is increased.
But in a pelvis so much flattened that this diminution in the proportion of
the posterior interspinous to the anterior is marked, the deformity will be
more easily and accurately ascertained in other ways. In fat women it is
not easy to feel the posterior superior iliac spines.

II. Internal pelvimetry is that which is really important, but it is also
more difficult and is very disagreeable to the patient. It is the measurement
of the diameters of the pelvic canal. Instruments have been made for this

LABOUR, PRECIPITATE AND PROLONGED

243

purpose, consisting of variously shaped metal rods with knobs at their ends,
which are intended to be applied to different points in the pelvic canal, so that
the distance between the points may be measured. These answer excellently
in the dried pelvis. But when the neophyte tries to use them on the living-
patient he finds that the pelvis contains a bladder and rectum, besides a
uterus and vagina, and a good deal of fibrous and muscular tissue, and that
these parts are resistant and sensitive, so that it is often difficult to feel
with the fingers the points between which measurement has to be made,
much more to get metal knobs into position and hold them in position
while distances are being measured. Internal pelvimeters are for this
reason practically useless. The best pelvimeter is the hand, and the time
when the pelvis can be exactly measured is immediately after delivery.
How to do this was first accurately and clearly described by Mr. Robert
Wallace Johnson in his System of Midwifery published in 1769. The pro-
ceeding should, therefore, in justice be spoken of as Johnson's method of

Fig. 46. — Direct pelvimetry, measurement
four inches.

Fig. 47.

-Direct pelvimetry, measurement
three and a half inches.

pelvimetry. It consists in introducing the whole hand into the pelvis, and
noting the part of the hand which fills the pelvis in the diameter which
it is wished to measure. The following measurements (given by Mr.
Johnson) are those of a man's hand of average size. They should be tested
and corrected if necessary by measurement of the hand of the operator.

1. The fingers being bent into the palm, and the thumb extended and
applied close to the middle joint of the forefinger, the distance between the
end of the thumb and the outside of the middle joint of the little finger is
four inches (Fig. 46).

2. In the above position the distance from the thumb at the root of the
nail, in a straight line to the outside of the middle joint of the little finger,
is three inches and a half (Fig. 47).

3. The fingers being in the same position, and the thumb laid obliquely
along the joints next the nails of the first two fingers and bent down upon
them, the distance between the outside of the middle joint of the forefinger
and the outside of that of the little finger is three inches and a quarter
(Fig. 48).

4. The hand being opened and the fingers held straight, the whole

244

LABOUE, PKECIPITATE AND PEOLONGED

breadth from the middle joint of the forefinger to the last joint of the
little finger is three inches (Fig. 49).

5. The fingers being so far bent as to bring their tips to a straight line,

Fig. 48. — Direct pelvimetry, measurement
three inches and a quarter.

Fig. 49. — Direct pelvimetry, measurement
three inches.

their whole breadth across the joint next to the nails is two inches and a
half (Fig. 50).

6. When the first three fingers are thus bent their breadth across the
same joint is two inches.

7. The breadth of the first two across the nail of the forefinger is one
inch and a quarter.

In any case in which labour has been difficult the length of the
obstetrical conjugate should be measured during
or after the third stage of labour in the way
just described. If it is less than four inches
it can be measured by Johnson's method more
accurately than in any other way. If it is more
than four inches its precise length ceases to be
important. As the transverse measurement at
the brim usually exceeds four inches it can
seldom be estimated in this way, but any
measurement at the brim that is less than four
inches can be taken in this way as accurately as
the conjugate. It is difficult to measure the
transverse at the outlet by Johnson's method,
because the resistance of the perineum is so
great ; but if there is reason to believe this
diameter contracted, its internal measurement
should be attempted. In the slighter degrees of
pelvic deformity, when the head is presenting
at the brim, Johnson's method cannot be applied
before delivery ; but if neither the head nor the
breech is presenting, or if the pelvic deformity is so great that the head
cannot at all sink into the pelvis, Johnson's method can and ought to be

Fig. 50. — Direct pelvimetry, measure
ment two inches and a half.

LABOUE, PEECTPITATE AND PEOLONGED

24f

applied before delivery with the assistance of anaesthesia. An inexperi-
enced person may fall into error from failing to get his hand into the
smallest diameter of the brim ; but this is a mistake that a little care will
guard against, and it is the only source of fallacy which attends Johnson's
method of pelvimetry.

It is often desirable to know the length of the obstetrical conjugate in
cases in which Johnson's method is inapplicable before delivery. In that
case the only way is to measure the diagonal conjugate, and infer from it
the length of the obstetrical conjugate. This can be done either in the
customary left lateral position or in the dorsal position. In the former
position the left hand must be used ; in the dorsal position either hand
may be employed. With the patient on her left side, the middle and index
fingers of the left hand
must be introduced into
the vagina and pressed
up until the middle
finger feels the sacral
promontory. One finger
cannot reach far enough
for this. The difficulty
in reaching the promon-
tory lies in the resistance
of the perineum, which
must be pressed up by
the knuckles of the third
and fourth fingers, and
this pressure on the peri-
neum is painful to the
patient. The amount of
pressure exerted depends
on the length of the
diagonal conjugate and
the thickness and firm-
ness of the pelvic floor.
One who is regardless of
the pain he causes can feel
the promontory in almost
any woman. But it is in practice not needful to much hurt the patient, for
if the promontory cannot be reached without very forcible upward pressure
it may be safely concluded that the conjugate is not much, if at all, shortened,
and its exact measurement need not be taken. When it is so contracted
that its exact measurement is important, it can easily be felt. When the
tip of the middle finger is in contact with the promontory the back of the
right forefinger should be applied to the front of the pubic symphysis, and
held at right angles to the radial border of the left index finger and palm, so
that the nail of the forefinger marks the spot at which the left examining
hand touches the pubic symphysis. Then the hands are removed, with the
right forefinger still in contact with the left hand, and the distance
measured from the right forefinger nail to the tip of the left middle finger.
This distance is the diagonal conjugate. It forms one side of a triangle,
the other side being the symphysis pubis and the true conjugate. The
length of the symphysis pubis is easily measured, and if we could as easily
measure the angle which it forms with the diagonal conjugate, we could
then from these data exactly calculate the length of the true conjugate.

Fig. 51. — Mode of measuring the diagonal conjugate.

246 LABOUK, PEECIPITATE AND PROLONGED

But to measure the inclination of the symphysis pubis requires special
apparatus, an assistant, and an amount of exposure and manipulation of
the patient that make this measurement impracticable in ordinary practice.
We are therefore obliged to be content with deducting from the diagonal
conjugate the average difference between it and the true conjugate, which
is a little more than half an inch, and thus inferring the true conjugate.
It may seem as if we ought not to be content with so rough an approxi-
mation, but it must be borne in mind that the measurements themselves
are only approximations, the points between which we have to measure
and the measuring instruments (the fingers) are so indeterminate that it is
impossible to get nearer than within about a quarter of an inch ; that is to
say, that different competent observers measuring the same patient, or a com-
petent observer measuring the same patient on different occasions, will get
results differing by at least a quarter of an inch from one another.

The accoucheur ought not in advising his patient to depend upon one kind
of measurement alone. If consulted during pregnancy he should take the
external measurements and the diagonal conjugate ; then judge of the size
of the child by palpating the belly, measuring its girth, and the height of the
uterus above the symphysis pubis ; and, finally, estimate the relative size of
the child and pelvis by trying how far he can press the head of the child
down into the pelvis. After delivery, for sure guidance in future labours,
he should accurately measure the true conjugate by Johnson's method, and
check the result obtained by examination of the child's head. He should
note any dints, grooves, overriding of sutures, red stripes on the skin, or
other evidence of compression, and measure the diameter of the head where
pressure has evidently been operative. From the information so obtained
he will be able to advise the patient with precision as to the mechanical
difficulties to be anticipated in subsequent labours, and as to the best mode
of delivery. Midwifery can only be regarded as a branch of medical science,
whence its practice is governed by a knowledge of the size and shape of the
pelvis, the size of the child, especially of its head, and the movements which
it ought to make in order to pass easily through the pelvis. Practice
without this knowledge is not science, but rule of thumb. The treatment of
difficult labour by persons who have not this knowledge is simply to lay
hold of the child with instruments or hand, and pull till either the child
comes out or the operator is exhausted. In the latter event he probably
sends for assistance ; and the person whose aid is sought finds a patient
irreparably damaged, and so ill that an operation by which she might have
been safely delivered early in labour, has become attended with extreme
danger.

The Tkeatment of Labour with Contracted Pelvis

Take first the most extreme case, a pelvis with a true conjugate of not
more than two inches. Here there is no doubt as to the proper treatment.
Cesarean section is the only mode of delivery. It is true that in the past,
when Csesarean section was terribly dangerous, expert handlers of the
cranioclast, vertebral hook, crotchet, and scissors nave broken up and
extracted a child through a pelvis with a conjugate a trifle less than two
inches ; but such operations are long and difficult, and entail a risk to the
mother as great as that now attached to Csesarean section. There is no
longer occasion for such operations.

Deformity of the pelvis so great as this is, is usually accompanied with
visible deformities of other bones; and therefore it is possible that the
possessor of such a pelvis may suspect that her pelvis is misshapen, and be

LABOUK, PRECIPITATE AND PROLONGED 247

wise enough to consult her doctor before she marries, before she becomes
pregnant, or in the early months of pregnancy. The suggestion may then
be made that the necessity for Csesarean section may be averted by the early
induction of abortion. But multiple pregnancies ending in abortion cannot
be gone through without a little risk, not to speak of the deterioration of
the patient's comfort and happiness by the repeated necessity for fruitless
operations. Csesarean section, followed by sterilisation, seems to me prefer-
able. It may also be suggested that the necessity for either abortions or
Cesarean sections may be avoided by the use of precautions to prevent
pregnancy, such as are commonly employed in another country with a
decreasing population. But these precautions are nasty ; they often fail,
and their prolonged use tends in many women to injure the nervous system,
as is illustrated by the complex forms of hysteria common in the country to
which I have referred, but happily rarer in England. But further, every
woman with a healthy mind is fond of children. Even if she before
pregnancy desired not a child, she will love and value it when she has got it.
If treatment gives the patient a strong and healthy living child, it gives her
the greatest treasure she can have. A patient may be so fond of children
that she will be willing more than once to incur the risk of Csesarean section,
and if so, her wish ought not to be opposed. I think a patient cannot
reasonably be expected against her wish to incur repeatedly a risk so much
greater than that of natural delivery, and that therefore if the patient wishes
that after Csesarean section further pregnancy should be made impossible, it
is proper to comply with this request.

Take next a pelvis having a conjugate diameter of more than two inch es,
but less than two inches and three-quarters, and without appreciable shorten-
ing of the transverse diameters. Here delivery by cephalotripsy, done by a
skilful operator, in a patient not exhausted by protracted labour, and in a
place in which asepsis can be secured, is attended with no greater risk than
that of labour at term. The immediate prognosis for the mother is there-
fore better if she is delivered by cephalotripsy than if Csesarean ' section is
done. The objections are (1) that the child's life is sacrificed, and the
mother deprived of the happiness of maternity ; and (2) if we look farther
into the future than the days of childbed, is the prognosis so much better
for the mother ? If she lives the life of a healthy married woman she will
probably have pregnancy after pregnancy, each with its discomforts and
dangers ; and the sum of these dangers to her life (not to speak of the
comfort of her life) will probably be as great as that of one Csesarean section.
I think that from the point of view of the mother's life Csesarean section,
followed by sterilisation, is to be preferred to cephalotripsy.

Consider next a pelvis with a conjugate of from two inches and three-
quarters to three inches and three-quarters, and not appreciably contracted
in the transverse diameters. Assume that the patient has been wise enough
to consult you early in pregnancy. There are two alternatives. One con-
siders solely the immediate interests of the mother. It is to induce labour
before the child is too large to come through the pelvis. If this is done
early enough the mother will have an easy labour, but the child will be
puny and difficult to rear. The time to choose for the induction of labour is
a compromise. The earlier the labour is induced the easier it is ; the later it
is postponed the stronger the child. Therefore it should be done at the very
latest time at which it is possible for the child to pass through the pelvis.

Measure the pelvis, and measure the uterus. The greatest girth at the
full term of pregnancy in a patient who is not fat, dropsical, or the possessor
of a tumour, and whose uterus contains a child of average size, with an

248 LABOUR, PRECIPITATE AND PROLONGED

average quantity of liquor amnii, should not exceed one yard — thirty-six
inches. The measurement in such a case from the symphysis pubis to the
top of the uterus, over its convexity, averages thirteen inches. At seven
months' pregnancy these measurements should be less. If the patient
thinks herself only seven months pregnant, and yet her measurements
approach those of an average full term pregnancy, there is need for investi-
gation as to the cause of her excessive enlargement. Palpate the abdomen,
and find out where the foetal head is. If it is not over the pelvic brim
perform external version if possible, and get it over the brim. When the
head is over the brim try how easily it can be pressed down into the brim.
If it can be pressed down easily into the brim, tell the patient to come
again in two, three, or four weeks' time, according to the ease with which
the head could be pressed down into the brim. As soon as the head just
fills the brim tell the patient that the time has come to induce labour.
This is the way by which the mother gets most safely and easily over
pregnancy and labour, but not the way by which the birth of a strong and
healthy child is best secured.

If the mother is willing, in order to have a strong and healthy living
child, to incur a little more risk, you can add half an inch to the conjugate
diameter by symphysiotomy. This operation, if done in suitable cases, and
by the subcutaneous method, is almost without risk. The ill results that
have occasionally followed symphysiotomy are either preventable, such as
haemorrhage and septic infection — risks almost abolished by the subcutaneous
method of operating ; or they have occurred in unsuitable cases — those in
which the pelvis was so small, or the child so large, that it could not be
pulled through the pelvis without excessive separation of the pubic bones.
If the pubic bones are pulled farther apart than two inches there is risk of
damage to the soft parts below them — urethra and bladder — and to the
sacro -iliac articulation. Before symphysiotomy is undertaken the patient
should be examined with as much care as before the induction of premature
labour, and the relation of the equator of the head to the shortest diameter
of the pelvis estimated. If the former diameter exceeds the latter by more
than half an inch symphysiotomy is not suitable.

"When the head presents not, the relative size of the head and the pelvic
brim cannot easily be determined. In this case try to turn the child by
external or bimanual manipulation, and get the head over the brim. The
possibility of this depends upon whether there is enough liquor amnii to
enable the foetus to move freely. If you cannot do this, the only guide as
to the possibility of delivering a living child by symphysiotomy is the
measurement of the pelvis and of the uterus. Measure the diagonal con-
jugate, and deduct half an inch from it to get the true conjugate. Measure
the greatest girth, and the distance from the symphysis is to the top of the
uterus, measured over the anterior convexity of the uterus. If the girth
exceeds not thirty-six inches, and the distance from pubes to top of uterus
exceeds not thirteen inches, you may safely assume that the child is not
larger than the average, and may be smaller.

The objections to symphysiotomy are : — First, the immediate risk to life
from (a) hseniorrhage, (b) septic poisoning. These risks attend every opera-
tion in which a large wound is made ; but they are preventable ; and if
symphysiotomy is done by the subcutaneous method, and with a clean knife,
they practically cease to attend it. Secondly, the risk of impaired power of
locomotion from imperfect union of the symphysis. The experience of
Ahlfeld and others shows that even when the two pubic bones are only
united by fibrous tissue (and it is doubtful whether they ever unite in any

LABOUE, PEECIPITATE AND PROLONGED 249

way) and remain separated by a larger interval than before the operation, the
patient can nevertheless stand and walk well. In some cases symphysiotomy
has permanently so enlarged the pelvis that the patient has been naturally
delivered afterwards. The cases in which permanent lameness has followed
have been those in which the two pubic bones have been separated excess-
ively, so that the ilio-sacral articulation has been injured. Thirdly, the
possibility of injury to the bladder or urethra, resulting in persistent want
of control over the bladder. This ill consequence is liable to follow when
the pubic bones are too widely pulled apart, and the soft parts between them
too much stretched and consequently torn. It is to be prevented by esti-
mating the relative size of the foetal head and the pelvis before deciding on
the method of delivery, and choosing symphysiotomy only if it is certain
that the head can pass through the pelvis after this operation. Fourthly,
the longer time during which the patient has to lie in bed after symphysio-
tomy ; four weeks, as opposed to two weeks after natural delivery. There is
really little in this objection ; because, although a woman can get up two
weeks after natural delivery, few women can fully discharge their household
duties so soon. The time from delivery to restoration of full working power
is about the same whatever the method of delivery, if the method chosen is
the right one.

Slight Pelvic Contraction. — Consider, lastly, the case of a patient whose
pelvis is not so much contracted that it can be said at once that an operation
of some kind is necessary for delivery. Though the pelvis is under normal
size, the disproportion between the pelvis and the head is not so great as to
put natural delivery out of the question. The first point is to take greater
care than usual to prevent premature rupture of the membranes. When the
patient is upright the weight of the amniotic fluid helps the uterine contrac-
tions to burst the membranes ; therefore the patient should be kept on her
side in the semi-prone position. In this position the weight of the waters no
longer is added to the force of the uterine contractions. If the patient can
be got to rest on her knees and elbows the weight of the waters opposes and
partly neutralises the effect of the uterine contractions. The patient should
be told not to strain. The attendant should be careful in examining not to
injure the membranes. Next, it is needful to bear in mind the difficulty
which the head has in engaging in a contracted pelvis ; the ease with which
in such a pelvis it may get displaced, even if it were over the brim at the
beginning of labour ; and the liability, even if the head present, of its being
forced into an unfavourable position, such as a face or brow presentation.
Therefore care should be taken to see that the long axis of the uterus is as
nearly as possible a continuation of that of the pelvic brim. Lateral
obliquity of the uterus should be corrected by making the patient lie on
the side opposite to that towards which the uterus leans. If there be
pendulous belly the patient should be put on her back and a firm binder
applied. If the position of the child is still unfavourable it should be, if
possible, corrected by external manipulations. Contraction of the pelvis
brings with it no special tendency to abnormalities of the pains, but the
effects of too weak or too strong pains are more serious than if bony obstruc-
tion to the passage of the child is absent. Weak pains, which with a pelvis
and child of average size would have only made the labour long, will, if
the pelvis be contracted, fail to make the head enter the brim. On the
other hand, if the pains are too strong, danger of rupture of the uterus
will arise early. Hence in contracted pelves the course of the labour must
be watched with greater care than usual, that an abnormal course of labour
may be early perceived and early treated.

250 LABOUE, PEECIPITATE AND PEOLONGED

If the rQembranes rupture early, as is often the case, before the os uteri
is near full dilatation, and the head does not come into the os uteri to
stretch it open, the best course is to artificially dilate the cervix with
Champetier's bag. Then when the os uteri is fully dilated the child can
be delivered either by forceps or turning.

The entry of the head may be made easier by putting the patient in
what is called " Walcher's position " ; that is, in the dorsal position on rather
a high bed so that the legs may hang down with the toes just touching
the floor. This position extends the pelvis upon the spine, rotating it about
a transverse axis passing through the sacro-iliac synchrondroses, and thereby
enlarges the conjugate by about from one to two-fifths of an inch. It at
the same time diminishes the antero-posterior diameter at the outlet ; so that
there is no advantage, but the reverse, in the patient's retaining this posi-
tion after the head has entered the pelvic cavity.

There has been discussion as to the relative merits of delivery by
forceps and by turning when the head is presenting in a flat pelvis. With
a small round pelvis, and the head presenting, if the head can enter the
pelvis no one questions that if help is needed it should be given with
forceps. But as to the best way of delivery in flat pelves, there has been a
difference in the teaching of different schools. It has been pointed out, and
is admitted, that the passage of the head base first is easier, because when
the parietal bones are pressed together from below upwards the angle they
form at the sagittal suture is made more acute, and the transverse measure-
ments of the head are diminished (see Eig. 24). When the child is born
head first the resistance to the advance of the vertex tends not to diminish
the transverse diameters of the head, excepting by the overriding of the pos-
terior parietal bone by the anterior, and by grooving and dinting of the bones,
and these changes in the shape of the head may be produced whether it comes
first or last (Pig. 52). To this it is replied that delivery with the feet first
involves so much risk to the child's life, from pressure on the cord, etc., that
the results are better when the child is delivered by
forceps. Statistics show that this has been the case
in some maternity charities. The explanation is,
that more skill is required to deliver a child alive
by turning than by forceps. Eorceps delivery only
needs hard pulling. But for the delivery of a
living child by turning it is essential that the right
time should be chosen, and that extraction should
be skilful and rapid. If the accoucheur fail to
fig. 52.-change in shape of head recognise the right time for version and bungles
su?eT"verter™dvance: extraction, the child wiU be dead. I think that in
Dotted lines, aa, 66, cc.normai flat pelves delivery by podalic version, skilfully

shape of head ; continuous r . -i -i p tV

lines, i, 2, shape of head done, gives better results than i orceps. Jb or success,

KerdS™efr^™abaiseo the bag of membranes must, if possible, be pre-

Fig- 24i) served until the os uteri is fully dilated. If this

cannot be done the os should be dilated with the water-bag of Champetier

de Eibes. When this bag has been expelled the child should be turned and

the head quickly extracted by combined jaw and shoulder traction.

There is one exception to the foregoing statement. If the head has
engaged in the brim in the most favourable position for passing it, this
state of things cannot be improved upon. The most favourable position is
that in which the long diameter of the head is transverse, and there is so
much Naegele obliquity that the sagittal suture feels as if distant about
three-quarters of an inch from the sacral promontory. In this position the

LABOUK, PRECIPITATE AND PROLONGED 251

diameter which passes the brim is a transverse subparietal super- parietal
diameter, which is rather less than the biparietal, and is further diminished
by the posterior lying parietal bone being overlapped by the anterior, and
being flattened by the pressure of the sacral promontory. Experience has
shown that a head thus engaged in the brim can generally be delivered with
forceps.

Faults in the Soft Passages

Delivery may be delayed by causes which prevent the proper dilatation
of the soft parts. By many writers (especially old writers) " rigidity " of the
cervix, or more briefly but incorrectly, "rigid os," has been described as a cause
of lingering labour, — a term which, as used, implies that there are cases in
which delivery is morbidly delayed because a healthy cervix will not dilate ;
and various methods of treatment — drugs to be swallowed, medications to
be applied, and manipulations to be performed — have been recommended,
having for their object the more speedy opening up of the healthy cervical
canal. It is rash to make negative statements because they cannot be
proved. But I must go as far as I can in this direction, and say that I
have never seen a case of labour, otherwise normal, delayed because the
cervix would not dilate ; nor have I ever read a report of a labour described
in such a way as to convince me that this was the case. I have read plenty
in which it seemed to me that the only fault was that the doctor was in a
hurry, and the dilatation was not quick enough to please him ; but this is
not enough to prove that it was abnormal. A healthy cervix in a natural
labour will always dilate if time be given ; and the time required depends
on the forces which effect dilatation. The proper treatment of slow dilata-
tion of the cervix is to search for the cause of slow dilatation, and treat that
if treatment other than by time be required.

The Causes of Slow Dilatation. — It may be (1) from uterine inertia ;
the uterine contractions, which ought to pull up the lower uterine seg-
ment, and so pull open the os uteri, and afterwards drive the bag of
membranes into it, are weak and infrequent. I have elsewhere described
the treatment of this condition. It may be (2) that the bag of membranes
which ought to enter the os uteri, and stretch it open with gradually in-
creasing power, is absent, either because the membranes have burst prema-
turely (the common cause), or because there is too little liquor amnii (a rare
thing). If so, dilatation is slow, because dilatation has to be accomplished
solely by the vertical fibres of the uterine body pulling up the lower uterine
segment until the os uteri is large enough to admit the presenting part of
the child. The first stage of labour is then long, to the great annoyance of
patient and accoucheur. If the head or breech of the child present, the
pelvis is normal, and the child of average size, with time the presenting part
of the child will come down into the os uteri and dilate it ; and the only
treatment required is to sustain the nerve force of the patient by food and
sleep. The patient should take as much food as she can keep down ; and if
she feels tired, but cannot sleep, a sedative should be given, either opium or
chloral. Some think that chloral has a specific effect, besides its utility as
a sedative, in helping dilatation of the cervix. This may be so, but I know
not that it has been proved. If used, a full dose, 3ss., should be given. A
grain of opium may be given, or the opium and the chloral may be combined.
With this treatment the cervix will in time dilate, and the patient will be
delivered naturally. If, however, from any cause, such as malposition or
excessive size of the child, or contraction of the pelvis, the presenting part
of the child comes not down to stretch open the os uteri, further help is

252 LABOUE, PEECIPITATE AND PBOLONGED

needed, and this is best given by the insertion of Champetier de Eibes'
water-bag. The mechanical action of this instrument in dilating the os
uteri is the same as that of the natural bag of membranes, which it effect-
ively replaces. It may be (3) because labour has come on prematurely.
When labour comes on at the full term the os internum has already been
dilated during the preparatory or so-called " secret " stage of labour, so that
the first stage of labour consists in the dilatation of the external os only.
But in labour which has come on, or been induced, prematurely, the os in-
ternum is not dilated, and the first stage consists in the dilatation first of
the internal and then of the external os. It consequently is slow. The
treatment of this consists in time, in letting the bag of membranes, and
then the presenting part of the child, have plenty of time in which to open
up the cervical canal. If the bag of membranes bursts too soon, and the
head or breech enters not the os uteri, then it should be dilated with
Champetier's bag.

Contracted pelvis, large size of the child, and abnormal presentations
are indirectly causes of slow dilatation of the soft parts, because they pre-
vent the head from coming down into the cervix uteri, and thus lead to
premature rupture of membranes, so that neither bag of membranes nor
foetal head dilates the os.

The natural shape of the os uteri externum is that of a transverse slit. In
a few women it is small and round ; and it may be so small that a probe will
not enter it. If pregnancy take place in such a uterus, the bag of mem-
branes cannot get into the os uteri. In such cases labour pains may con-
tinue for twenty- four or thirty-six hours without producing any appreciable
dilatation of the os uteri. The treatment of such cases is to dilate the os
uteri, first with bougies, and then with the finger, until the bag of mem-
branes can get into it. Labour pains that have been going on for many
hours will have made the os uteri big enough to admit a bougie. When
the bag of membranes is able to enter the os uteri dilatation goes on with
normal rapidity.

, The cervix uteri may dilate badly because it is diseased. It may be
contracted by cicatricial tissue. The tears in the cervix by which a first
labour is generally completed do not contract the os uteri, but rather widen
it, for the scar tissue binds together the mucous membrane of the vaginal
aspect and that of the cervical canal. But when part of the cervix has been
destroyed by ulceration, syphilitic or other, or by sloughing, then cicatricial
tissue may form part of the circumference of the os ; and fibrous cicatricial
tissue is incapable of stretching. The possibility of dilatation of the os
uteri, and the rate at which such dilatation will go on, depend on the pro-
portion of healthy tissue to scar tissue in the cervix uteri. If the scar
tissue only forms a small part of the ring of the os, the healthy tissue may
be capable of stretching enough to let the child pass. But if the whole or
the greater part of the os uteri is bounded by cicatricial tissue, natural
dilatation cannot be hoped for, and the os uteri must be enlarged by
incision. A probe-pointed bistoury is the best instrument to use. The
edge should be guarded by wrapping it with strapping up to the terminal
inch. With it several incisions should be made radiating from the centre
of the os, and then delivery completed by pulling upon the pole of the foetal
ovoid which presents : either upon the head with forceps, or upon the breech
by means of the leg.

Pregnancy may take place in a uterus the subject of cancer of the cervix.
Whether such disease retards dilatation of the cervix or not depends upon
its hardness, not upon its extent. Some cancers are much harder than

LABOUR, PRECIPITATE AND PROLONGED

253

others. One case has been published in which the cancer was so hard that
the cervix dilated not, labour pains, after long continuing ineffective,
ceased, and the child was retained in the womb for ten months after-
wards. Others have been observed in which the whole cervix and adjacent
tissues were a mass of cancer, and yet delivery was quick and easy. Hence
in the treatment of labour complicated with cancer of the cervix, the only
guide is observation of the course of labour. If the cervix opens up
quickly no treatment is required. If early in labour it is noticed that
the cervix is very hard, and that the bag of membranes has no effect upon
it, the patient should be delivered by Csesarean section. The forcible
dragging of a child through a hard mass of pelvic cancer entails a risk to
the mother which is probably as great as that of Csesarean section when
performed under favourable conditions. Csesarean section, if the child is
living, will deliver it alive. In cancer of the cervix, unless the disease
can be removed, the mother will die soon, probably after much suffering ;
so that this is a case in which the life of the child may be considered
as more valuable than that of the mother. If the cancer is limited to the
vaginal portion of the cervix, this should be amputated notwithstanding
the pregnancy. If it is not discovered till the patient is in labour, and the
greater part of the cervix is healthy, the healthy part of the cervix will
dilate and the child be born naturally. When child and placenta
have been expelled (assuming that there is no doubt as to the diagnosis,
and as to the limitation of the disease to the uterus), the uterus should be at
once removed by the vagina. Experience has shown that the uterus can be
easily and safely removed immediately after delivery, for although the uterus
is very vascular, yet the genital canal is at this time so patent that the uterus
can easily be pulled down, and the vessels secured.

The pregnant uterus with cancer of the cervix has more than once been
removed entire by abdominal section. This proceeding subjects the patient
to unnecessary risk. It is safer
to induce premature labour or
abortion, and then, after delivery,
to remove the uterus through the
vagina. This course is desirable, be-
cause cancer of the uterus grows faster
during pregnancy owing to the in-
creased vascularity of the uterus ; and
because if left the cancer will probably
extend beyond the uterus, and then
its removal will be impossible.

Delivery may be obstructed by an
ovarian tumour. Such a tumour can
only obstruct delivery if it be small
enough to remain in the pelvic cavity.
In that case what happens depends
on the size of the tumour. If it be
small enough the child may pass
through the pelvis in spite of the
presence of the tumour. If it be
so large that the passage of the
child, though possible, is yet difficult, the tumour will be squeezed
and bruised during delivery; and this may cause haemorrhage into
the tumour, or inflammation of it, during childbed. Dermoid tumours
are especially liable to this because they grow slowly, and are therefore

Fig. 53. — Ovarian tumour obstructing delivery.
(After Tyler Smith.)

254 LABOUR, PEECIPITATE AND PROLONGED

more apt to remain long of small size and in the pelvic cavity. The
bruising during delivery lowers their vitality, so that they become a
prey to microbes, which cause suppuration. In the course of such suppura-
tion they often rapidly enlarge ; so that a tumour which was not discovered
during delivery, even by repeated vaginal examinations, may within a fort-
night become big enough to displace the uterus and cause retention of urine.
A suppurated dermoid is the commonest cause of retro-uterine abscess in
childbed. Dermoids sometimes grow in the pelvic cellular tissue ; and when
a dermoid behind the uterus has suppurated, it is not clinically possible
to say whether the dermoid has grown in the cellular tissue, or whether
it is an ovarian dermoid adherent in Douglas's pouch ; and it is not very
important.

If an ovarian tumour lies in the pelvic cavity, and is so large that the
head cannot possibly pass it, the accoucheur should first try to push it up
above the pelvic brim. Early in labour, before the membranes have
ruptured, it will generally be possible to do this. If the head has advanced
so far into the pelvic cavity that the tumour cannot be pushed up, the
question is, Can the accoucheur remove it ? The answer to this question
will depend partly upon the features of the tumour, and partly upon the
accoucheur's knowledge and experience in dealing with ovarian pedicles, and
the instruments he has at hand. If he is familiar with the details of
ovariotomy, and has the necessary instruments, he should if possible remove
the tumour by the vagina. He should cut through the posterior vaginal
wall (for the pedicle of the tumour will be behind the uterus), and thus
expose the tumour, and bring it out into the vagina. Then transfix and
tie the pedicle. Next seize the pedicle on the distal side of the ligature
with two strong pressure forceps, and then cut away the tumour. This
done, carefully examine the pedicle to see that it is not bleeding, removing
first one pressure forceps, then replacing it and removing the other. When
satisfied that the pedicle has been securely tied, release it, and sew up the
vaginal incision. This is the ideal treatment of an ovarian tumour which
obstructs delivery. Its practicability will depend on the length of the
pedicle, the presence or absence of adhesions, and the skill of the operator.
Should the operator judge it wiser not to attempt the removal of the
tumour, then he should make an incision into it, and pass a stitch on each side
to unite the tumour to the vaginal incision. The resistance of the tumour
will be removed by its evacuation ; and by stitching it to the vagina any
infection of the peritoneum by the contents of the tumour will be avoided.

If pregnancy is complicated with a tumour too large to remain in the
pelvis, the mutual effects of the pregnancy and the tumour may be im-
portant. The distension of the abdomen will be increased. The bearing-
down efforts of the patient by which delivery should be helped, will be
exerted at a disadvantage. Lastly, there is a liability to twisting of the
pedicle of the tumour. For these reasons an ovarian tumour should always
be removed as soon as it has been discovered, whether the patient be
pregnant or not ; and even if it has not been found out till the patient is
in labour, it should be removed then, unless the labour is so far advanced
that delivery is likely to take place during the operation.

Pregnancy sometimes takes place along with uterine fibroids. Although
fibroids are common, pregnancy with fibroids is not, because fibroids occur
chiefly after the child-bearing age. If pregnancy occur with a fibroid, the
tumour usually gets larger, softer, and more vascular during pregnancy,
and then after delivery it undergoes involution — gets smaller, harder, and
less vascular. I have known a fibroid disappear during puerperal in-

LABOUR, PRECIPITATE AND PROLONGED

255

volution of the uterus. A subperitoneal fibroid situated above the pelvic
brim interferes in no way with pregnancy, labour, or lying in. A submucous
or interstitial fibroid often causes changes in the endometrium which are
inimical to the occurrence of pregnancy ; but pregnancy may occur with
such a tumour. It is often said that such tumours interfere with uterine
contractions, make labour lingering, and cause post-partum haemorrhage.
But in my judgment the evidence in support of these statements is
insufficient. It has not infrequently happened that the accoucheur has put
his hand in the uterus, discovered the tumour, and without difficulty has
enucleated and removed it. In some the tumour has been spontaneously
expelled after delivery. In others, which are rarer, the foetal head has
driven the tumour down before it, broken through its attachments, expelled
it, and so cured the patient.

If a fibroid is situated in the cervix or lower part of the body of the
uterus, and is so large that there is no possibility of the child's head getting
past it, there are only two alternatives. One is to remove the tumour ; the
other to perform Csesarean section. If the tumour is accessible it can
probably be easily enucleated. The methods of enucleating uterine fibroids
are described elsewhere. The only point special to enucleating a fibroid in
a pregnant uterus is that its capsule will be very vascular, so care must be
taken to see that after its removal the uterus drives the foetal head down
upon the site of the tumour. If this does not happen, the place of the
foetal head should be supplied by a dilating bag, that so the bleeding part
may be pressed upon and haemorrhage restrained. If the tumour is so large
and so situated as to obstruct delivery, and it cannot be easily and safely
removed, it is best to perform Cesarean section, after which the uterine
arteries can be tied, and the body of the uterus with the tumour removed.

Lastly, after delivery a fibroid may invert the uterus, just as it some-
times does an unimpregnated uterus. If the fibroid is so far driven down
that its equator gets below the internal os, then when the internal os
contracts the tumour will be driven farther down, and may pull the body of
the uterus after it. The treatment is to
peel off the fibroid and then reduce the
inverted uterus. If it is undertaken
soon, this can be easily done, by pressing
the inverted fundus up with one hand,
and at the same time steadying the
cervix uteri and dilating the os internum
with the fingers of the other hand on the
abdominal wall.

Delivery may be obstructed by tumours
of the pelvic bones. These may be exostoses.
These are especially apt to grow where
there is cartilage — at the symphysis
pubis, the sacral promontory, and the
sacro- iliac synchondrosis; and where
tendons are inserted — the psoas minor
and Gimbernat's ligament. The pelvic
bones may also be irregularly thickened by
periostitis. Exostoses of the pelvis are
seldom so large as to obstruct delivery, but they make laceration of the
vagina more apt to occur, the mucous membrane being nipped between
the head and a bony spine. Pelves presenting exostoses have been
styled " spiny " or " thorny " pelves, or " acanthopelys."

Pig. 54.— Sacral exostosis.

256

LABOUR, FAULTS IN THE PASSENGER

The commonest large tumours in the pelvis are enchondromata and

sarcomata. Enchondromata usually
grow from near the sacro-iliac syn-
chondrosis, and are larger than most
other pelvic tumours. Sarcomata,
especially osteosarcomata, sometimes
completely block the pelvic canal.
Fibromata grow from the periosteum ;
they are seldom large, but may be
large enough to obstruct labour.
Secondary growths of cancer may occur
in the pelvic bones. Hydatids may
invade the pelvic bones, and form a
tumour bulging into and narrowing
the pelvic cavity, although I know
not of a case in which such a tumour
has obstructed labour.

No detailed rules can be laid down
for the treatment of cases of labour
obstructed by a tumour ; for the cir-
cumstances vary infinitely, according
to the size, position, and nature of the
tumour. All that can be said is, that if the pelvic space is so narrowed
that a living child certainly cannot be born, Csesarean section is generally
indicated. This operation will effect the birth of a living child with less
risk than that involved in dragging a mutilated child past a new growth.

Fig. 55. — Cancerous growths from pelvic bones.

Faults in the Passenger

Otherwise Labour obstructed by Anomalies in the Ovum

Liquor Amnii

(a) Excessof: Hydramniosor Poly-

hydramnios

(b) Absence of: Oligohydramnios .

Membranes

(a) Thinness of .
(6) Toughness of ...

Prolapse of

Anomalies of

Placenta

Cord

256

258
258

259
259

259

260

Child

(a) Death of .-Post-mortem Rigidity :

Emphysema . . .260

(6) Large Size of: in Head Pre-
sentation . . .261
In Breech Presentation ; Im-
pacted Breech . . .262

(d) Malformations and Disease of:

Hydrocephalus and Encepha-

locele . . . .264

Spina bifida, Hydrothorax,
Ascites, QfJdema, distended
Bladder, etc., Cystic Kid-
neys and other Tumours . 265

(e) Monstrosities: Acardiac . . 265

Anencephalic . 266
Exomphalic . 266
Conjoined twins 266

Liquor Amnii

(a) Excess of Liquor Amnii : Hydr amnios, Polyhydramnios, or Hydrops
Amnii. — For a complete description of this condition see " Pathology of

LABOUR, FAULTS IN THE PASSENGER 257

Pregnancy." We consider it here merely as a complication of labour. Though
the quantity of liquor amnii is, as a rule, between one and two pints, it is
impossible to observe two or three hundred cases of labour without seeing
instances in which the quantity rises to two or three quarts, and occasion-
ally several gallons of fluid may be found in the uterus. But while labour
in some women is not appreciably affected by a very considerable excess of
liquor amnii, a moderate amount of distension of the uterus by fluid causes
marked disturbance in the labours of others. We cannot therefore define
hydramnios as a complication of labour, by any reference to the quantity
of fluid present, but only by the alteration in the ordinary course of labour
which is observed to occur. Suppose we see a woman who is undoubtedly
in labour, but whose pains are weak, infrequent, and ineffective. She com-
plains of difficulty in breathing and perhaps of nausea and vomiting. The
abdomen is more distended than usual, and the whole abdominal swelling
being dull on percussion, it is not partially due to flatus. If the distension
were due to the presence of twins or to the complication of pregnancy by a
fibroid tumour, palpation of the abdomen would reveal the presence of a
solid body. If, however, there is fluctuation, it is necessary to distinguish
between hydramnios, pregnancy complicated by ovarian or parovarian cyst,
and pregnancy with ascites. The last named can be excluded by percussion
with the patient in various positions, and when a large cyst accompanies
pregnancy the uterine contractions which can be felt in one part of the
abdomen are absent over another. The diagnosis of hydramnios during
labour is thus much easier than the recognition of the same condition earlier
in pregnancy.

In making a forecast as to the result of a labour complicated by
hydramnios, it is necessary to remember that such labours are generally
premature ; that the foetus is generally ill-nourished or otherwise imperfect ;
and that, if not dead before labour begins, it often dies soon after birth.
Further, as the foetus floats freely in an enlarged cavity, no definite lie is
assumed, and mal-presentation is accordingly frequent. The prognosis is thus
bad for the child. The mother suffers but slight risk to life. The disten-
sion of the uterus causes uterine inertia during all stages of labour. If left
to nature there is a slow first stage, a slow or obstructed second stage, ex-
haustion, a risk of post-partum haemorrhage, and the attendant risk of sepsis.
If treated by early evacuation of the liquor amnii, there follows, as a rule,
the need for artificial dilatation for the cervix, which is preferable to the risks
to which the patient is exposed by delay. The prognosis for the mother is
thus somewhat unfavourable, unless modified by special care and exertion
on the part of the accoucheur.

The abdomen must be supported by a firm broad binder, and the uterine
contractions should be stimulated by friction. It is still usual to give ergot,
as in other cases of uterine inertia ; but quinine is rapidly becoming recog-
nised as a more suitable drug for this purpose. Given in doses of 4 grains
every hour for three or four hours, it favours alternate contractions and
relaxations, much more useful than the somewhat permanent contraction
seen after the administration of active doses of ergot. Indeed, in hydramnios,
as in general, difficulties in delivering the child and the placenta are often
avoided by adhering to the general rule never to give ergot until the uterus
is empty. In slight cases it is often possible to avoid breaking the general
obstetric rule which forbids artificial rupture of the membranes before
dilatation of the cervix is complete. In severe cases, on the other hand,
the symptoms caused by distension may indicate evacuation of the fluid as
soon as the diagnosis of hydramnios is made. It is usual to advise partial
vol. vi 17

258 LABOUK, FAULTS IN THE PASSENGEE

or gradual removal of the liquor amnii by means of an aspirating needle or
a small " valved " opening high up in the uterus, the object being the pre-
servation of the " fore-waters." These suggestions, though traditional, are
not practical ; but before rupturing the membranes, it is always possible to
secure, by artificial dilatation of the os, sufficient room to admit of bipolar
version. Having passed one hand into the vagina and dilated until the os
easily admits two fingers, simply puncture the membranes, check the flow of
liquor amnii by plugging the vaginal outlet more or less completely with
the wrist, and observe the lie of the fcetus. If the head presents and enters
the pelvis in a good position it may be left alone. The simplest way of
avoiding future difficulty, however, is to secure and pull down a foot, and
draw the half breech well into the partly dilated cervix. As the prognosis for
the child is so poor, it is not worth while to attempt to secure head-first
delivery. The case may now be left to nature, or may be terminated by
manually completing dilatation and delivering the child. Abdominal pressure
must be kept up while this is being accomplished, and extra care must be
used during the third stage. Supra-pubic pressure should be made for some
time after the removal of the placenta, in order to minimise the risk of post-
partum haemorrhage. Ergot may now be given to overcome the uterine
inertia common in these cases. To obviate the tendency to subinvolution,
quinine, iron, and strychnine may be given during the puerperium, and hot
vaginal douches will also be found of service.

(b) Deficiency or Absence of Liquor Amnii : Oligohydramnios. — Some-
times the quantity of liquor amnii produced is less than a pint.
This condition is discussed under " Pregnancy, Pathology of," but must be
referred to here in so far as it affects the course of labour.

The foetal parts are made out by abdominal palpation more easily than
usual, and the abdominal tumour is small. Vaginal examination during a
labour pain reveals the absence or small size of the bag of fore-waters.
Periodic examination shows that the pains are not effective in dilating the
cervix.

Nature's hydrostatic dilator, the bag of fore-waters, being wanting, the
first stage is slow, and the risks attending exhaustion on the one hand and
interference on the other are incurred.

During pains, the head should be pushed upward, so as to allow all the
liquor amnii which is present to be forced past the head into the bag of
fore-waters. Care must be taken to avoid rupturing the membranes during
this manoeuvre. If fluid is present only to the extent of a few ounces,
enough can be collected in front of the head to form a useful bag of waters.
Failing natural dilatation, the os must be opened by patient work with the
fingers or by the use of hydrostatic dilators. The best of these for this
purpose is the conical inelastic bag of Champetier de Eibes, which was
originally designed for the induction of premature labour, and which is now
largely used in cases of accidental hsemorrhage and placenta prsevia. The
bag can be introduced through the cervix uteri as soon as the os will admit
the passage of two fingers. It is then almost but not quite filled with an
aseptic fluid by means of a syringe. The conical bag then replaces the
natural bag of waters, and when it has been expelled by uterine action
through the cervix into the vagina, dilatation is sufficient to allow the
second stage of labour to proceed. If labour pains are weak or infrequent,
dilatation may be aided by gentle traction on the stalk of the bag.

(c) Early Escape of Liquor Amnii : " Dry Labour." — Premature
rupture of the membranes may be caused by careless examination
during a pain. If the membranes are unduly thin they may

LABOUK, FAULTS IN THE PASSENGEK 259

break spontaneously under the pressure of uterine contractions at the
beginning of labour. When the presentation or position is faulty, or when
the shape of the pelvic brim is unusual, the presenting part does not fit
accurately into the lower uterine segment, and may fail to shut off the fore-
waters from the liquor amnii contained in the general uterine cavity. In
these cases the whole " general contents pressure " during a pain acts upon
the unsupported portion of membranes occupying the dilating os. The
result is the descent of the bag of waters into the vagina as a sausage-shaped
protrusion. Under these circumstances, if not very tough, the membranes
will rupture early, and the rest of the labour will be " dry."

In " dry labour " the first stage is slow and painful. The head, unpro-
tected by the bag of waters, is more liable to injury from pressure than
usual ; the soft parts are also exposed to pressure from the uncovered head.
The risks attendant upon exhaustion and interference must be remembered.
The management consists in artificial dilatation, which may be accomplished
as above mentioned, either manually or by hydrostatic dilators, the best of
these, as in the previous case, being the bag of Champetier de Kibes.

Membkanes

(a) Thinness of the Membranes. — The obstetric interest of this condition
depends upon the fact that unduly thin membranes are easily ruptured under
circumstances such as those mentioned in the previous paragraph. In other
words, the condition is a predisposing cause of early escape of the liquor amnii
and subsequent " dry labour " (which see).

(b) Toughness of the Membranes. — Tough membranes do not rupture at
the usual time, namely, as soon as dilatation is complete — in other words, at
the commencement of the second stage of labour. Sometimes a child is born
with its face and head covered by a portion of the membranes known as a
caul ; and occasionally birth is completed even at full time without any
rupture of the membranes, the ovum being expelled complete, the mem-
branes and placenta forming a sac containing the child and liquor amnii.
Persistence of the membranes after dilatation is complete offers considerable
resistance to the descent of the fetal head (or breech). Artificial rupture
of the membranes is therefore indicated as soon as the cervix and lower
uterine segment are completely canalised. Some authorities hold that this
method of hastening the second stage of labour should not be employed in
first labours, as they consider that the bag of waters is of value in dilating
the vaginal orifice. Artificial rupture of the membranes must be performed
with aseptic precautions, not during a pain, lest the rush of waters should
carry down a loop of the cord. Care must be taken to avoid injuring the
foetal scalp and the maternal passages. The safest method is to pinch up a
bit of membrane and tear it outward. If this cannot be done with the
fingers it may be managed with a pair of artery forceps. A sterilised hair-
pin or any other blunt instrument may be used.

(c) Adhesiotfof the Membranes to the Lower Uterine Segment. — We define
the lower uterine segment, for practical purposes, as that portion of the body
of the uterus which is passive and becomes dilated during labour. Its sur-
face is altered in shape during the first stage from that of a cup to that of a
tube. It is clear that in the formation of the bag of waters and dilatation of
the cervix, a movement of the membranes over the surface of the lower
uterine segment is absolutely unavoidable. Thus if the membranes are
adherent to the lower uterine segment, and do not break, dilatation cannot
occur. Complete adhesion of this kind is of course theoretical ; but ad-

260 LABOUK, FAULTS IN THE PASSENGEE

hesion sufficient to delay dilatation considerably is a practical difficulty, and
results from inflammatory conditions of the endometrium during early
pregnancy. Diagnosed by touch as soon as a finger can be passed through
the os internum, this condition is easily removed by sweeping the finger
round the os, separating the membranes from the uterine surface for a
distance of about two inches all round.

Placenta

Prolapse of the Placenta. — This rare occurrence occasionally causes
mechanical obstruction to the course of labour. It presupposes premature
separation of the placenta, and is generally met with in connection with
the delivery of already dead children. The diagnosis is easy and the treat-
ment is obvious. In placenta prsevia (see " Pregnancy, Haemorrhage during ")
delivery is frequently mechanically obstructed by the placenta. It is some-
times necessary to deliver through the organ, and this procedure is by no
means always fatal to the child.

Cord

(See also " Anomalies of the Cord," and " Prolapse of Cord," p. 267).
Mechanical difficulty in labour may be caused by " absolute " or by relative
or " accidental " shortness of the umbilical cord, which may be only a few
inches long, or, while of full length, may be so wound round the child that its
free portion is not long enough to permit of delivery without separation of the
placenta. The second is the commoner variety of shortness. A strong cord
may resist the expulsive powers to the extent of fifteen pounds' weight, and
may thus greatly delay or completely arrest labour. Premature separation
of the placenta may result seriously, endangering the life of the child, and
exposing the mother to severe hsemorrhage. Inversion of the uterus is
another possible result of shortness of the cord. The diagnosis of retarda-
tion of labour by absolute or accidental shortness of the cord is very difficult,
especially before the head is born. If, however, the head recedes markedly
between pains, and if labour lags without any other ascertainable cause,
this condition will be suspected to exist. The escape of blood before the
head is born suggests premature separation of the placenta and points to
the same conclusion. In such cases forceps should be applied, or if the
breech presents, delivery should be attempted by traction and abdominal
pressure.

When the head is born the cord is generally within reach of palpation.
It should be clamped or ligatured in two places and divided between them.

Child

(«) Death of the child has long been associated in the minds of obstet-
ricians with prolonged labour, and has often been mentioned as a cause of
delay — the effect being mistaken for the cause. There are, however, certain
carefully recorded cases 1 in which post-mortem rigidity has been present in
the body of a dead child during labour, and has for some time prevented that
undoing of the foetal attitude, that unflexing of the trunk and limbs of the
child, which is an essential part of the mechanism of labour.

The conditions under which post-mortem rigidity occurs in utero have
not been sufficiently observed to permit of any statement as to the time and
1 Ballantyne, Eclin. Obstet. Trans. 1894-95.

LABOUE, FAULTS IN THE PASSENGEE 261

rate of onset, the duration or the termination of the condition. Its diagnosis
is practically impossible, except by direct palpation. The treatment, were a
diagnosis made, would be expectant, opium and other sedatives being
employed to check the progress of labour and give time for relaxation of
the foetal body to occur.

Decomposition of the dead foetus in utero sometimes causes various
parts of its body to become distended with gas to such an extent as to
impede delivery. This condition, which is known as emphysema of the
foetus, is recognised without difficulty by touch, the distended tissues yield-
ing with a " crackling " feel, under pressure by the finger. The abdomen
and thorax should be punctured, and the skin may be freely incised in
accessible places in order to allow the escape of the gas. Delivery under
these circumstances must be followed by energetic antiseptic measures.

(b) Large Size of the Child. — Though it is not one child in a thousand
that weighs over twelve pounds at birth, there is no more common cause of
delay during labour than relative largeness of the foetal head, for cases are
constantly met with in which the head is a trifle larger, while the pelvis
is a trifle smaller than the average. In these cases, the second stage is
prolonged, considerable time being demanded for the process of moulding,
By which alone the passage of the head through the bony pelvis is rendered
possible. Further delay is caused by the need for extra dilatation of the
vaginal orifice, and tears of the perineum frequently occur. Though the
head is usually the source of difficulty in the delivery of large children,
broad shoulders sometimes become impacted in the pelvis, and frequently
cause or increase perineal tears. Further, in pelvic presentations, the breech
of a large child is liable to become impacted in the maternal passages. It
is thus clear that the delivery of large children demands considerable care.
Prolonged gestation is doubtless a common cause of excessive size of the
foetus. It is stated that pregnancy is prolonged over 300 days in at least
6 per cent of women. We may say, then, that the size of the child de-
pends in part upon its age at the time of birth. The sex of the child
must also be considered, as male children are well known to be slightly
larger than females. Advanced age of one or both parents is said to favour
large size of the child, but this may be simply because it tends to cause
prolongation of pregnancy. Large size of one or both parents also conduces
to overgrowth of the foetus. It is certain that in many instances the size
of the children increases in successive pregnancies. This is usually noticed
in women with rather small pelves whose earlier children have been born
spontaneously, forceps extraction, and occasionally craniotomy, being
necessary at their subsequent confinements. It must be remembered that
in the passage of a large head through an ordinary pelvis, the disproportion is
exactly the same in nature as that which obstructs the passage of a normal
head through a generally contracted pelvis (see Justo-minor Pelvis, p. 220).
The modifications in mechanism and in treatment are accordingly the same
in both conditions. The head cannot enter the brim with the vertex pre-
senting, and therefore becomes more flexed than usual, the presenting part
thus being behind the vertex. In extreme cases the presentation is, in fact,
" occipital." This is important in diagnosis and in management. For
unusual flexion of the head at the beginning of labour — presentation of a
part behind the vertex — is a good and sufficient physical sign that the head
is too large for the pelvis. Again, this mechanism of extra flexion implies
that there is no room to spare in the sides of the pelvis, in other words that
the case is not one of fiat pelvis. This at once contra-indicates turning for
exactly the same reasons which forbid version in justo-minor pelvis.

262 LABOUB, FAULTS IN THE PASSENGEB

As to management, Hirst goes so far as to say that no woman should
be allowed to exceed the normal duration of pregnancy (280 days) by more
than a fortnight. Other authors advise that in cases where trouble from
this cause has occurred in previous labours the patient should be examined
periodically from about a month before full time, and that when it becomes
difficult to make the head enter the pelvis by abdominal pressure labour
should be induced (see " Obstetric Operations "). Largeness of the head,
however, is as a rule diagnosed only when unusual flexion of the head is
discovered early in labour. The treatment consists in the application of
the forceps as soon after the cervix is completely dilated as the operator
deems consistent with the safety of the perineum. The advocates of sym-
physiotomy consider large size of the head to be a good indication for this
operation, and unless it is certain that the child is dead, the symphysis
should always be divided in preference to perforating the head of the child.
But it is only very rarely that either of these measures is needful. It is
almost always possible to deliver a large child alive with the forceps, if
advantage be taken of the variations in the dimensions of the pelvis which
can be produced by altering the posture of the patient.1 Given a patient in
the lithotomy posture, the outlet of the bony pelvis can be increased by
pressing the thighs against the abdomen till the knees approach the shoulders.
Similarly, the conjugate at the brim, i.e. the inlet to the bony pelvis, can
be increased by allowing the legs to hang down (the feet not touching the
ground), so that their weight draws the symphysis away from the sacrum,
the whole pelvis rotating on an axis passing through both sacro-iliac joints.
This " hanging legs position," or Walcher's posture, is of advantage when-
ever difficulty is met with in making the head enter the pelvis. The rules
are as follows : — (1) Apply the forceps with the patient in the lithotomy
posture. Place pillows under the buttocks, and while pulling the head
through the brim into the pelvis allow the legs to hang down. (2) Bemove
the pillows, and while pulling the head out of the bony pelvis press the
thighs against the abdomen, so increasing the pelvic outlet. (3) Whilst
pulling the head through the vulvar orifice allow the legs to hang down
once more, as this relaxes the skin of the adjoining parts and minimises
tearing of the perineum. After the birth of the head some difficulty may
be experienced in delivering a large body. Firm pressure on the fundus
will favour rotation of the shoulders and their passage into and through
the pelvis. When either of the axillse can be reached, it forms a point
d'appui for traction by the finger, which must be made carefully and in the
pelvic axis, abdominal pressure still supplying the major part of the force
employed.

In pelvic presentations large size of the child may act as a cause of
impaction of the breech. If labour is delayed, although dilatation is com-
plete and pains are good, this condition is to be suspected. The size of the
presenting part should be reduced by bringing down one or both of the
feet if this is possible, as it almost always is when the knees are flexed.
Nature may then complete expulsion, or it may be necessary to deliver by
traction and supra-pubic pressure (see " Management," p. 201). The attitude
of the foetus may, however, be the Cause of impaction, for when the knees
are extended, the feet being near the head and the pelvis flexed upon the
trunk at the lumbar articulations, the trunk, pelvis, and legs form a wedge
which cannot pass though the bony portion of the parturient canal. As
flexion of the spine is essential to the formation of the wedge, the condition

1 Author's Manual of Midwifery, Edin., Clay, 1896, p. 413 ; also Edin. Med. Journal,
July 1895

LABOUR, FAULTS IN THE PASSENGER 263

is immediately removed if a foot can be brought down, and this should
therefore be done as soon as possible.

In any case in which the feet cannot be reached traction may be used,
by means of a finger passed into the groin. A piece of aseptic material,
such as a well-boiled handkerchief, may well be used for traction, one end
having been slipped over the groin and pulled down between the legs. The
blunt hook is not a safe instrument for this purpose, nor is the forceps seen
at its best when applied to the breech. If it become necessary to break up
the pelvis of a child the best instrument is a cranioclast or a cephalotribe.
When this has been done the head must be perforated, lest the child should
be born alive.

(c) Unusual Ossification of the Cranial Bones. — This condition causes
difficulty in labour by preventing " head-moulding," which should reduce
the head both laterally and in the antero-posterior direction. Eor the
occipital bone slips under the parietals, and these in turn under the frontal,
the head segments thus being telescoped ; and also one parietal bone slips
under the other, the upper one being that which is anterior (relative to the
mother's pelvis) before rotation occurs. It is clear that when ossification
has advanced to the sutures both these movements are prevented in some
degree, and the diameters of the head during labour are those of a larger
cranium.

Three reasons for undue ossification may be noted. (1) Ossification may
be precocious or premature. (2) If gestation be prolonged and the child is
thus older than usual when born, normal ossification is further advanced
than it generally is at the time of birth. (3) There are occasionally extra
centres of ossification round which are formed the so-called Wormian bones
between the usual cranial bones. These prevent head-moulding by inter-
fering with the overlapping of the cranial bones at the sutures. Wormian
bones are most often found in the posterior fontanelle and in that extra space
known as the sagittal fontanelle, which is said to occur in 4 per cent of
infants between the parietal bones, in a line joining the two parietal eminences.
Peckham has recorded three cases of still-birth in which Wormian bones
were the cause of death by preventing overlapping of the cranial bones.1

The diagnosis of undue ossification of the cranium is made by vaginal
examination after dilatation has advanced sufficiently to permit of direct
palpation of a considerable portion of the head. The prognosis is some-
what more unfavourable than when the head is merely large, because head-
moulding cannot gradually improve the situation. In breech presentations
it is even more difficult to save the child's life than when the head leads.
The mother is exposed to the usual risks attendant upon delay and inter-
ference. The management differs in one particular from that appropriate
in cases where the head is large, for when the cranium is ossified firmly there
is nothing to be gained by allowing time for head-moulding to occur, whereas
when the head is merely large the longer it is possible to wait with safety
before delivery, the easier is the extraction of the child. When undue
ossification has been diagnosed, therefore, the operator should apply the
forceps as soon as dilatation of the cervix is complete and the vaginal outlet
is sufficiently soft. He should then deliver with the patient in Walcher's
position, as described under the previous heading. If delivery is found to
Tbe impossible by this method, it is necessary to ascertain whether the child
is dead or alive. If it is living symphysiotomy is indicated, while if it is
dead the head should be perforated and extracted after comminution with
a cranioclast. Walcher's position is, of course, as useful in delivering the
1 New York Med. Record, April 1888.

264 LABOUR, FAULTS IN THE PASSENGER

after-coming head as in cases where the head leads. When perforation of
the after-coming head is necessary the best position for the insertion of the
perforator is the roof of the mouth.1 The base of the skull is well broken
up by this method, and the grip afforded to a cranioclast allows of easy
extraction.

(d) Malformation and Disease of the Child : Congenital Hydrocephalus
(see "Hydrocephalus"). — Cases of congenital hydrocephalus as diagnosed
after birth are much commoner than cases in which this condition causes
difficulty in labour. The fluid occupies the cavities of the brain, or occa-
sionally the sub-arachnoid space. In most cases the bones are widely
separated, the sutures and fontanelles being greatly extended. In some
cases of slight degree the bones reach the sutures and cover the whole
cranium, but are much thinned. The presentation is said to be pelvic once
in every five cases. In these breech presentations the base of the skull,
which is not enlarged by disease, is first to enter the pelvis, and acts as
the thin end of a wedge. Spontaneous delivery is therefore more frequent
in breech than in head-first cases. Many heads, however, are so plastic as
to pass through the pelvis after moulding has occurred. The cranium may
burst under the pressure of the natural forces, or the fluid may pass from
the cranial cavity and occupy a position under the scalp. As the large head
stretches the cervix and lower uterine segment transversely as well as
longitudinally, rupture of the uterus is the accident most to be dreaded.
Out of thirty-eight maternal fatalities due to hydrocephalus, rupture of the
uterus was the cause of death in no less than twenty cases.

On bimanual examination the head is felt to be large and soft, and is
found to rest above the brim. The bones yield before the finger in a
manner suggestive of brown paper. In breech cases the head does not
follow the body, and its size and character can be recognised by abdominal
palpation.

The prognosis is bad as regards the child. If the case is diagnosed early
and actively treated there is little risk to the mother. If unrecognised
these cases are grave, on account of the risk of ruptured uterus.

In the management of cases of hydrocephalus sufficiently marked to
obstruct labour no attempt should be made to save the life of the child. If
born alive these infants seldom survive long. The body is often small and
shrunken, while malformations such as spina bifida are frequently present.

The use of the forceps should be avoided, as the grip is wide and unsatis-
factory. The handles refuse to come together, showing that the blades are
widely separated. Under these circumstances slipping and injury to the
maternal soft parts are very likely to occur.

The perforator should be used at an early stage, and if natural
expulsion does not follow in due course after the escape of the fluid, delivery
should be completed by means of a cranioclast or a cephalotribe. In breech
cases traction often bursts the head, or at least forces the fluid into an extra-
cranial position under the scalp, so permitting delivery. If perforation of
the after-coming head be necessary it may be done through the roof of the
mouth or behind the ear. If neither of these places is within reach, Van
Heuvel recommends the removal of the fluid by means of a catheter, which
is passed through an opening made into the spinal canal, and so upward
through the foramen magnum into the cranial cavity.

Encephalocele. — Tumours of this nature are occasionally of sufficient size
to delay or to completely obstruct labour. They may be either encephalocele
proper or meningocele, the cranial substance being spread over the surface
1 Donald, Trans. Obstet. London, vol. xxxi.

LABOUE, FAULTS IN THE PASSENGEE 265

in varying degree. There may or may not be a communication between
the sac and the cranial cavity through the pedicle, which may be either
broad or narrow. Tumours of this kind are usually in the middle line, the
occipital region being their commonest site, and the frontal the next in
frequency. The extra fontanelles known as the cerebellar, the naso-frontal,
and the medio-frontal correspond to weak points in the cranium, where
outpushings of the membranes and cerebral substance are liable to occur.
The diagnosis may be very confusing, and demands careful examination, the
whole hand being introduced into the uterus if necessary.

Spina bifida seldom causes actual difficulty in labour, as the tumour is
seldom large. The condition may be myelocele or meningocele, and is often
found along with hydrocephalus. It sometimes causes difficulty in
diagnosis when the presentation is pelvic.

Hydrothorax has very occasionally been recorded as a cause of delay in
labour. In conjunction with ascites it is of more frequent occurrence.

Ascites has been observed in connection with other manifestations of
syphilis, and also with new growths of various abdominal organs. It some-
times accompanies hydramnios. Apart from associated conditions it seldom
obstructs labour.

(Edema of the fetus may be caused by malformations of the fcetal
circulatory organs, or may be associated with placental disease. It has been
described by Spiegelberg as occurring in cases of congenital syphilis. There
may be overgrowth of connective tissue and skin in addition to distension
of the cellular tissue by fluid.

Distended Urinary Organs. — Owing to developmental errors the urethra
is sometimes imperforate, when the fetal bladder may become enormously
distended. The ureters may also be imperforate, when the proximal portions
may form tense tumours of considerable size. Hydronephrosis occurs under
similar circumstances.

Fcetal New Growths. — The condition known as congenital cystic kidney
may produce great enlargement of the foetal body, and may completely obstruct
labour. Ovarian cysts and various neoplasms of the liver, spleen, and
pancreas have also been reported as having produced the same result. The
occurrence of an "included fetus" within the body of another must be
remembered as a possibility, also the sacral teratoma.

The diagnosis of the above-mentioned conditions is, of course, extremely
difficult, and indeed no definite conclusion as to the cause of obstruction can
be arrived at, as a rule, until the difficulty has been overcome and the
fetus extracted. The general principles upon which such cases should be
managed are as follows : — The life of the child must not be considered as of
any importance. The life of the mother must not be exposed to risk by
delay in ending labour. The means used to reduce the bulk of the fetus
vary according to the circumstances of each case. The choice lies between
multiple incisions into the fetal body, evisceration and morcellement. A
large pair of scissors will be found to be the most serviceable instrument ;
the blunt hook is also useful. The perforator and cranioclast may be
employed as need arises.

(e) Monstrosities : Acardaic Monsters. — In twin pregnancy, when one
embryo is less developed than the other, the heart of the stronger may so
overpower that of the weaker that blood is forced from the single placenta
up the umbilical arteries of the weaker embryo. This so disturbs its fetal
circulation that atrophy of the heart follows, the result being the production
of an acardiac monster, whose lower parts, being nourished by the blood
pumped into them through the umbilical arteries, grow rapidly, while the

266 LABOUR, FAULTS IN THE PASSENGER

development of the upper portions is arrested for want of a proper blood-
supply by the umbilical vein. The heart and upper parts are therefore
represented by a mass of cellular tissue of low form not differentiated into
organs, the lower limbs alone being recognisable as such. These monsters
generally present by the feet, and are seldom large enough to cause serious
difficulty during labour. Incisions may, however, be necessary, and
occasionally the monster must be cut into several pieces and so removed.

Anencephalic monsters are characterised by absence of the brain and of
the vault of the skull. The face looks upward, the neck being short and
broad. The body and limbs are often very large and well developed. The
absence of a properly shaped cranium tends to favour errors in presentation,
and thus difficulty in labour is often caused. In head cases the face pre-
sents, and the diagnosis demands care. The small head does not dilate the
passages enough to admit of ready delivery of the large shoulders. Again,
owing to its size and shape, the head affords a very poor grip to the forceps.
Delivery is easiest head last, and turning should accordingly be the treat-
ment adopted, when this is feasible.

Exomphalos and Ectopia Viscerum. — Imperfect development of the
anterior abdominal wall causes some portion of the abdominal viscera to lie
outside of the body of the foetus, occupying what is practically a dilated
umbilical cord. In the extreme cases — those of complete ectopia viscerum
— there is no cord at all, and the placenta forms one wall of the cavity in
which the viscera are contained. In these cases the placenta must be
separated before the child can be born, and considerable hsemorrhage is
likely to occur. Serious difficulty is met with in those cases in which the
foetus is developed in a position of retroflexion. The fcetal attitude of
flexion is lost and the back is hollowed, the upper portion of the foetus
being extremely rigid as a rule. Under these circumstances it is necessary
to manipulate the foetus in such a manner that the curve of its body shall
correspond with the curve of the parturient canal, a manoeuvre which is by
no means easy.1 Cases in which a minor degree of exomphalos occurs rarely
present serious difficulty (see also " Teratology ").

Double Monsters. — Conjoined twins obstruct labour in ways so varied
that no definite rules can be laid down for their delivery. For this reason
a detailed description of their varieties forms no part of practical obstetrics.
Herman's classification, however, is useful. He arranges double monsters
in three groups : —

(1) Those in which one end of the foetus is double.

(2) Those in which two foetuses are loosely connected.

(3) Those in which two foetuses are closely connected.

In (1) there are two heads more or less fused together (double-faced
monster) ; or else the pelvis and lower extremities are duplicated. If seen
early in labour, when the whole hand can be passed into the uterus, these
conditions can be made out. A double head should be perforated ; if there
are two separate heads one of them should be cut off. A reduplicated pelvis
should be divided into portions with large scissors or a sharp hook.

In (2), the connection between the foetuses being loose, labour is seldom
seriously impeded, and any difficulty which may arise is of the same nature
as those encountered in locking of twins (which see), and must be dealt with
on similar lines. It is necessary, however, to make a complete diagnosis
between " double monster " and " locked twins," in order to avoid destruc-
tion of both twins when it might be possible to save one alive- This remark
also applies to class (3), in which the most difficult cases are likely to occur.

1 Murray Cairns, Trans. North of England Obstet. and Gyn. Soc. 1900.

LABOUK, ACCIDENTAL COMPLICATIONS

2G7

The rule most generally applicable is to bring down the feet of one fetus,
and then proceed to embryotomy as circumstances may direct.

Playfair's classification of conjoined twins is also useful. It is as
follows : —

(1) Two foetuses united more or less completely face to face by thorax
or by abdomen.

(2) Two foetuses united back to back by the lower portion of the spinal
column.

(3) Dicephalous monsters with single body and two heads.

(4) Two separate bodies, the heads more or less united.

Out of thirty -one cases collected by Playfair, twenty labours ended
spontaneously, and parturition was fatal to the mother in only one case.
Pelvic presentations were the most favourable, and turning was several
times successful.

Accidental Complications affecting the Child only

Abnormalities of the Cord —

Presentation and Prolapse

267

Knots of the Cord

271

Coils of the Cord .

271

Torsion of the Cord

272

Rupture

272

Undue Shortness of

272

Pressure on the Cord

273

Prolapse op the Arm . .273
Dorsal Displacement of the

Arm 274

Prolapse of the Foot . . 274
Injury to the Foetus during

Labour ..... 274

Still-birth .... 275

A. Abnormalities of the Coed

(i.) Presentation and Prolapse. — These are by far the most important
complications, not only on account of their frequency, but because of the
serious effect on the life of the child. The umbilical cord is a somewhat
slender connecting line between the placenta and the foetus, by means of
which the nutrition of the child is maintained during pregnancy and
parturition. Under the normal conditions of intra-uterine life the cord
lies in a place of safety, free from injury and undue pressure, on the ventral
aspect of the foetus. Should it depart from this position, and come to lie
over the presenting part, serious danger to the child will arise. It is import-
ant to clearly distinguish between the terms " presentation " and " prolapse "
of the cord. " Presentation of the cord " is the term applied to those cases
in which the umbilical cord can be felt lying over the presenting part of
the foetus, and in which the membranes are unruptured. The term " pro-
lapse of the cord " is used for those cases in which the membranes are
ruptured, and the cord projects through the cervix or descends into the
vagina, or even appears at the vulva. If in any case the condition known as
presentation of the cord is not recognised the more serious complication of pro-
lapse is certain to follow so soon as the membranes rupture. All cases of
prolapse of the cord are not necessarily preceded by presentation. In some
cases the abnormal position of the cord occurs quite suddenly at the time
of rupture, and in other cases the cord is gradually extruded during the
progress of labour along the side of the presenting part. The cord may
form a tense band over the presenting part, or it may descend as a loop
through the cervix into the vagina.

Frequency. — The frequency of prolapse of the cord appears to vary con-
siderably, judging from the statistics obtained from the different maternity
institutions in this country and abroad. According to Spiegelberg it occurs

268 LABOUK, ACCIDENTAL COMPLICATIONS

once in 86 cases. In the Dublin Eotunda Maternity the frequency was 1
in 200 cases. In other British maternity institutions it seems to be a less
frequent complication, occurring about once in every 400 or 500 cases.
Simpson has suggested that the increased frequency of prolapse in the
German schools may be due to the dorsal position in which the parturient
women are delivered. In this position the long axis of the uterus forms an
angle of about 30° with the vertical, and the action of gravity would there-
fore assist the descent of the cord. In the left lateral posture, however, the
long axis of the uterus is horizontal, and the fundus may be even on a lower
level than the cervix, consequently there would be no tendency for the cord
to descend towards the lower segment of the uterus under normal conditions
of the fcetus and pelvis.

Causes. — Where the pelvis is of normal size, the child presenting with
the vertex, and the muscular wall of the uterus not unduly lax, there is
very little tendency for the cord to present, owing to the close adaptation
of the presenting part to the lower uterine segment. After rupture of the
membranes this apposition of the presenting part to the lower segment of
the uterus is still closer, as shown by the manner in which a considerable
amount of amniotic fluid is retained after escape of the fore-waters, and
therefore the chance of the cord becoming prolapsed is minimised. In cases
of pelvic, including footling presentations, and in transverse or shoulder
presentations, these conditions do not obtain to the same extent, so that pre-
sentation and prolapse of the cord is not uncommon. Again, in cases of
hydramnios and twin pregnancies the excessive distension of the uterus
interferes with the normal relation between the presenting part and the
lower uterine segment. The same result may be brought about in cases of
obliquity of the uterus and cases of pelvic contraction. Prolapse of the cord
occurs more frequently in multiparas than in primiparse, because in the
latter the head lies more deeply in the pelvis in the last few months of
pregnancy and at the commencement of labour. The greater frequency of
this accident in cases of excessive length of the cord and low insertion, as in
cases of placenta prsevia, is easy to understand. Sudden rupture of the
membranes occurring whilst the patient is in the erect posture may be a
cause of prolapse of the cord, but it is more often associated with some
other predisposing cause, such as undue length or contraction of the pelvis.

Diagnosis. — Before rupture of the membranes the cord can be felt as a
movable coil lying over the presenting 'part, and may be overlooked unless
a careful examination is made. After rupture the presence of a loop of
cord in the vagina is easily recognised, and it is hardly conceivable that any
mistake in the diagnosis could arise. It has . been mistaken for a coil of
small intestine, but the absence of any mesentery is at once evident, and
the presence of the pulsating umbilical artery confirms the diagnosis.
Pulsation in the cord is, however, not always an available means of dis-
tinguishing between the two, as it is absent where the foetus is dead or
where the cord is exposed to pressure. In the former case the cord hangs
down as a flaccid loop. "When pulsation in the cord cannot be felt the
death of the child should not be assumed till after careful auscultation of
the fetal heart.

Prognosis. — The mortality to infant life from prolapse of the cord is very
high, and depends on the time at which it occurs, and also on the form of
presentation. As a general rule, the danger to the child, so long as the
membranes are intact, is not great. So long as the cord is only " present-
ing " it is only exposed to intermittent pressure, which does not endanger
the vitality of the child. The later the cord becomes prolapsed the better

LABOUK, ACCIDENTAL COMPLICATIONS 269

the prognosis for the child, since the condition of the parts will be more
favourable for rapid delivery. When, owing to early rupture of the
membranes, the cord becomes early prolapsed the danger to the child is
very great. Prolapse of the cord is more serious in vertex presentations
than in breech, since the cord is exposed to more dangerous compression
against the hard surface of the head. In cases of placenta prsevia and
pelvic contraction the prognosis is very unfavourable. Prolapse of the cord
is not in itself a cause of danger to the mother, except in so far as this
complication calls for active interference in the course of labour, which
otherwise might have been allowed to run its natural course.

Treatment. — All methods of treatment which are employed for this
complication have for their object the saving of child life. Probably few
cases occur in midwifery practice where the results depend more on the
judgment and skill with which the necessary manipulations are carried out.
Success in treatment — and by success one understands the delivery of a
living child — depends on early diagnosis of the prolapse. The possibility
of this complication makes a vaginal examination after rupture of the
membranes a necessary routine practice. If the cord can be felt presenting
make a careful examination in order to decide whether the child is alive or
dead. Seeing the comparatively small danger to the child so long as the
membranes are intact one important indication is to avoid their premature
rupture. For this reason' the woman should be kept in bed during the
period of dilatation. An attempt should be made to remove the cord from
its unfavourable position by placing the patient in the genu-pectoral posi-
tion. In this attitude the fundus uteri becomes the most dependent part,
and the cord gravitates towards the fundus. The woman should be kept in
this position for about ten minutes, and should then be instructed to lie
well over on her side with the hips raised by means of a pillow. In some
cases, when the head descends after rupture of the membranes, it may force
upwards a loop of cord previously presenting out of the way, but this
favourable result cannot be relied upon. A careful watch must be kept on
the foetal heart, and the obstetrician must be prepared to interfere if the
condition of the foetus calls for it. Should the cord again present after its
replacement by the postural method it is best to perform bipolar version,
bringing the leg down into the vagina. The half-breech will act as a plug
in the lower segment of the uterus and prevent further prolapse.

Where the membranes are found ruptured when the woman is first seen,
and the cord prolapsed, the treatment to be adopted depends on the present-
ation and also on the extent to which the cervix is dilated. It will be
convenient to consider cases of vertex presentation first.

If the cervix is only large enough to admit two fingers an attempt may
be made to replace the cord by means of a repositor. Emplacement with the
fingers is rarely satisfactory at this stage, as it is seldom possible to push up
the cord into a position where it will remain, unless the whole hand can be
introduced through the os. Special instruments are made for the purpose
of replacing the cord, called repositors, but a new English catheter, size No.
10, answers the purpose well, and has the advantage of always being avail-
able. If a catheter is used it is necessary to cut a small hole in the end of
the catheter opposite the eye, and to pass a piece of tape through it. The
piece of tape is then passed round the loop of prolapsed cord near its end, '
and fixed to the end of the catheter sufficiently tightly to prevent its
slipping through, but still allowing for circulation in the umbilical vessels.
The stylet is now introduced along the catheter to give it the necessary
stiffness, and it is passed up with the loop of cord into the uterus. The

270 LABOUR, ACCIDENTAL COMPLICATIONS

stylet should then be withdrawn, but the catheter is left in situ, as it in no
way interferes with the course of labour. The foetal heart must be carefully
watched, and should it show signs of failing other means must be resorted
to. Should the cord again prolapse after its reposition, further manipula-
tion is harmful to the child, and it is safer to have recourse to bipolar version
while there is still a chance of saving the child.

If the os is sufficiently dilated to admit the hand when the case is first
seen two methods of treatment are possible. In the first place, an attempt
may be made to carry up the loop of cord in the palm of the hand past the
head, and to hook it over one of the lower limbs. When this has been done
the further progress of the case may be left to the natural forces should the
cord remain in utero. Should the cord, however, again descend, the safety
of the child will best be ensured by passing the hand up into the uterus,
seizing a leg, and bringing it down into the vagina.

Lastly, certain cases are met with where the os is dilated to three-fourths
its full size when the prolapse is discovered. Under these circumstances
rapid completion of the delivery by means of forceps is indicated. It [is
probable that in this operation a certain amount of laceration of the cervix
will occur, and in the case of a primipara the perinseum may also be
extensively lacerated as a result of the rapid delivery. It must be re-
membered, however, that these injuries to the mother are capable of
immediate repair, and are not followed by any permanent injury, whereas
in the case of the child its life is in serious jeopardy. It is, therefore, not
only justifiable, but it is good practice, to risk these possible injuries to the
mother in the interests of the child. In this country all are agreed that
the first duty of the medical attendant is towards the mother, where the
question of treatment concerns the life of the mother versus the life of the
child. In the present instance this is not the point at issue. What we
have to weigh in the balance is the life of the child as against a traumatism
to the mother, which with proper antiseptic treatment is readily repaired,
and for this reason the life of the child claims our consideration.

It is necessary now to consider what line of treatment should be adopted
where prolapse of the cord is associated with presentations other than vertex.
In cases of breech presentation the pressure on the cord, and therefore the
danger to the child, is rarely so great as in vertex presentations, owing to
the less resistant character of the presenting part. The best treatment is
to pass the hand up and bring down a leg. This not only diminishes the
size of the presenting parts, but the half-breech readily adapts itself within
the lower segment of the uterus, and prevents the cord from again becoming
prolapsed. Further, the presence of the leg in the vagina enables the child to
be delivered rapidly by traction upon it should the foetal heart show signs
of weakness or slowing of the beats. In the case of oblique or shoulder
presentations the treatment called for to correct this abnormal presentation
will remove the cord from its position of danger.

Where prolapse of the cord is associated with a flattened pelvis, reposi-
tion of the cord should not be attempted, as it is unlikely that it will be
followed by any permanent results, owing to the shape of the pelvic inlet,
which prevents the descent of the presenting part, and so interferes with
its adaptation to the lower uterine segment. The best result will be
obtained by performing bipolar or internal version, according as the os
admits only two fingers or the whole hand. If the contraction of the
pelvis is of such a kind that the delivery of a living child after the per-
formance of version is not to be expected, it is best to replace the cord by
means of a repositor, and to extract with forceps as soon as the cervix is

LABOUR, ACCIDENTAL COMPLICATIONS 271

sufficiently dilated to admit the passage of the child without undue risk to
the mother.

Lastly, cases occur in which the prolapse of the cord is a complication
of placenta prsevia. The best method of treatment in these is to replace
the cord with the hand, the patient lying in the latero-prone position on
her left side, with the hips slightly raised. After pushing up the cord out
of the way introduce a de Eibes' bag into the lower segment of the uterus,
and distend it with boiled water or weak carbolic solution. The distended
bag not only checks further haemorrhage during the dilatation of the os,
but its presence in the lower uterine segments prevents the cord from again
becoming prolapsed. After expulsion of the bag into the vagina the
delivery of the child can be rapidly completed.

It is hardly necessary to add that in all cases where no pulsation can
be felt in the cord, and where, after careful auscultation of the abdomen, no
evidence of a living child can be obtained, the case must be treated accord-
ing to the presentation found, and the fact that the cord is prolapsed may
be entirely disregarded.

(ii.) Knots of the Cord. — This complication is usually associated with
abnormal length of the cord. Knots are primarily caused by the foetus
slipping through a loop of the cord during the active movements that
occur in the course of pregnancy. The knots may become tightened either
during pregnancy or at the time of labour. Those which occur during
pregnancy are usually more lightly knotted, and the constrictions produced
in Wharton's jelly are readily observed after expulsion of the placenta.
Cases in which the knotting has occurred during labour are more readily
unravelled, and leave no indentations. Occasionally a double knot is
caused by the fetus passing through two loops, either consecutively or
with one movement, owing to the two loops being apposed. It rarely
happens that the knots are drawn so tightly as to interfere with the circu-
lation through the umbilical vessels, but in rare cases this may be a cause
of intra-uterine death.

(iii.) Coils of the Cord. — Coiling of the cord round the neck of the child
is an exceedingly frequent occurrence, being observed as often as once in
every ten cases. One or more coils may be found. When there is only a
single coil there is little probability of any serious trouble arising in the
course of parturition. Where the cord is coiled two or more times
round the neck abnormal presentations may result, owing to the acquired
shortening of the cord, resulting from the coiling interfering with the
normal lie of the child. Again, the constriction caused by the cord may
lead to interference with the blood -supply to the foetus, and in this way
asphyxia or even death of the foetus may result during delivery.

Where coiling of the cord occurs round the limbs of the foetus they may
give rise to marked constrictions of the limb, which may extend through
the soft tissues down to the bone. Under these circumstances the limb
presents a curious appearance at the time of birth. Cases have occurred
where the distal portion of the limb has become entirely separated in con-
sequence of this gradual constriction. Where several coils of the cord
encircle the neck of the child, a further danger may arise during the expul-
sive stage of labour owing to the shortening of the cord causing premature
detachment of the placenta. Severe haemorrhage may then occur, both
during labour and after the expulsion of the child. It is important in all
cases of labour, as soon as the head is born, to pass the finger round the neck
of the child to see whether this complication is present. Unless the finger
is passed up to the neck coiling of the cord may easily be overlooked, as

272 LABOUK, ACCIDENTAL COMPLICATIONS

the swollen labia and perinseuni may conceal it from view. Where one or
more coils are found, it is usually quite easy to draw the coil down so as to
slacken the loop and slip one or more coils, as the case may be, over the
head. In some cases where the child is being rapidly born there may not
be time to draw down the coil and slip it over the head, and it is necessary
to slacken the loop and allow the shoulders to be delivered through the
loop. In very exceptional cases it may be necessary to divide the cord with
scissors and deliver the child forthwith.

(iv.) Torsion of the Cord. — This may occur to an abnormal extent in the
last few months of pregnancy, and may cause death of the foetus. It does
not occur during labour, and cannot lead to any interference with the normal
course of labour. It is not, therefore, necessary to consider it in the present
article.

(v.) Rupture of the Cord. — This accident occurs only in cases of precipitate
labour, when the patient is suddenly and unexpectedly delivered in the
upright posture. The effect on the child is twofold. In the first place, the
child is deprived of the additional amount of blood which passes into its
circulation, where ligation of the umbilical cord is delayed till ten minutes
after the delivery of the child. Furthermore, haemorrhage may occur from
the torn end of the cord, though this is not usually serious, owing to the
retraction of the walls of the vessels. The rupture usually occurs a short
distance from the umbilicus. This accident rarely happens in cases of
natural labour, and it can only occur when the cord is abnormally thinned
or coiled round the foetus.

To produce rupture of the cord rapid escape of the foetus is essential.
It is not necessary for the placenta to be still adherent, as the contraction
of the cervix after expulsion of the foetus is quite sufficient to hold back
the placenta, and in this way fix the opposite end of the cord. Where the
cord is much twisted, and presents thinner parts in places, the liability of
rupture occurring in consequence of some sudden strain is greatly increased.
The reason why rupture more often occurs near the umbilicus is found in
the fact that abnormal torsion and thinning of the cord are more often
found in this situation. Kupture occasionally takes place in the course of
instrumental delivery and during the performance of version. As soon as
the child is born the torn ends should be ligatured so as to prevent further
haemorrhage. Where it is not possible to ligature the cord as a whole,
owing to the proximity of the rupture to the umbilicus, the bleeding vessels
should be picked up separately and tied.

(vi.) Undue Shortness of the Cord. — This is a rare complication of
delivery. It is more common for apparent shortness to occur as a result of
coiling of the cord round the neck of the child in vertex presentations, or
owing to the child riding on the cord in the case of pelvic presentations.
In the latter case the cord is stretched down between the thighs and up
over the back of the child towards the placenta. Shortness of the cord,
either actual or relative, can only affect delivery during the later stages of
expulsion. During the early stages of expulsion progress is gradual, and
the uterus retracts down as the child descends through the parturient canal.
In the later stages of delivery a short cord may interfere with further pro-
gress, owing to the stretching of the cord between the umbilicus and the
placental site preventing further advance of the presenting part. Certain
signs are said to be suggestive of this condition, but none are actually
diagnostic. These are descent of the presenting part during the pains with
some haemorrhage, followed by recession in the intervals, in cases where there
is no marked resistance of the soft parts of the pelvic floor ; also dragging

LABOUK, ACCIDENTAL COMPLICATIONS 273

pain referred to the placental attachment of the cord. Certain diagnosis is
usually only possible when the cord can be felt tense and stretched.
Examination per rectum may assist the diagnosis, when the shortening is
due to coiling of the cord round the neck, and the descent of the head is
prevented. The treatment of relative shortness of the cord due to coiling
round the neck has already been described. Where the child rides on the
cord the treatment consists in drawing down a loop of the cord, flexing the
posterior knee, and slipping the loop of cord over it. After this the
foetal heart must be watched, and should it show signs of failing, rapid
delivery must be effected. Where there is actual shortening of the cord it
may in rare cases be necessary to divide the cord with scissors, following
this up by immediate delivery.

(viii.) Pressure on the Cord. — In all cases of labour where the breech
or lower extremities present, the umbilical cord is necessarily exposed to
pressure during the expulsion of the child. In normal delivery the amount
of pressure is not sufficiently great to interfere with the circulation in the
umbilical vessels, owing to the latter being embedded in the elastic envelope
formed by the jelly of Wharton. Where, however, there is any undue
resistance in the parturient canal, as in the case of priiniparse, the pressure
on the cord may be a serious complication, and it may be especially
injurious during the passage of the head through the pelvis. Great danger
is present where the after-coming head is delayed in cases of pelvic con-
traction. In these cases the cord is likely to be compressed between the
resistant head and the bony rim of the pelvis, and the child will soon perish
from asphyxia unless immediate delivery is possible. In some cases of
forceps delivery, where the cord is coiled round the neck of the foetus, death
of the foetus has been caused by one blade of the forceps pressing on the
cord and obstructing the circulation. Such an injury can usually be avoided
by careful vaginal examination previous to application of the forceps.

B. Prolapse of Arm

Prolapse of one or other upper extremity occurs under two conditions.
It may be prolapsed and occupy the vagina in cases of shoulder presenta-
tions, or it may be prolapsed in cases of vertex presentations. The former
will be considered in the article on shoulder presentations, the latter is an
accidental complication of what might otherwise be a normal delivery.
Slight descent of the upper limb may be found in the early stages of dilata-
tion, and may disappear as the head engages more deeply. When the arm
is found more deeply prolapsed by the side of the head there is usually
some want of adaptation between the head and the lower uterine segment.
It is found in cases of contracted pelvis and in lateral deviation of the
head, and may suddenly occur at the time of rupture of the membranes.
Death of the foetus predisposes to prolapse of the arm, inasmuch as the
normal attitude may be lost. Prolapse of the arm does not necessarily
interfere with the progress of labour, though it may in some cases. The
posterior part of the pelvis affords the most available space, and is therefore
the most favourable position for the prolapsed limb. If the arm becomes
prolapsed in front of the head it is more likely to cause the head to be
wedged into the brim of the pelvis. Further progress of the head is thus
prevented, and the prolapsed arm may be damaged or even fractured. The
diagnosis of the condition is readily made, and by careful examination of
the head it is not difficult to decide which arm is prolapsed.

The treatment consists in pushing up the arm, if this is possible, special
VOL. vi 18

274 LABOUK, ACCIDENTAL COMPLICATIONS

care being taken to press the arm towards the ventral aspect of the child.
Failing this, perform internal version. If the head has passed the pelvic
brim, and is lying in the cavity of the pelvis, leave the case to nature, as
delivery may follow without interference. If delay occurs at this stage it
is best to complete the delivery with forceps, taking special care to avoid
damaging the prolapsed extremity during the application of the blades.

C. Dorsal Displacement of the Arm

This is a rare complication of pelvic presentations, and occurs still less
frequently in some cases where the vertex presents. In pelvic presentations
this displacement may be caused by injudicious attempts to rotate the body
of the child during the delivery of the trunk, or it may occur in the absence
of any manipulations, in which case it is due to failure of the arm following
the rotation of the trunk. The forearm of the child in this way comes to
lie behind the nape of the neck, and interferes with the descent of the after-
coming head through the pelvic brim. The treatment consists in attempt-
ing to rotate the body of the child in the opposite direction to that which
caused the displacement, then seizing the forearm, and bringing it down over
the front of the chest. Where the displacement occurs as a complication of
vertex presentations, the projection caused by the arm interferes with the
descent of the head through the cavity of the pelvis. Diagnosis is often
very difficult. It may sometimes be possible to feel the arm above the
pubes, but in other cases the delay in descent of the head can only be
explained by passing the hand up past the head and ascertaining the posi-
tion of the arm. Having found this condition, the best means of treatment
is to perform internal version.

D. Prolapse of Foot

This is a frequent occurrence in case of pelvic presentations, and may
be artificially produced when version has been performed. These will not
be discussed now. The cases of prolapse of the lower extremity which may
be considered as an accidental complication are those in which the foot is
prolapsed by the side of the head. The causes are similar to those already
described as giving rise to prolapse of the arm, being especially frequent in
dead and premature children. Where the condition is found associated
witli vertex presentations an attempt may be made to push upwards the
limb, and to press the head down into the pelvis. Failing this, it is best
to pull on foot, and at the same time press the head upwards toward the
fundus, in this way producing a footling presentation.

Injuries to the Fcetus during Labour. — It will be convenient here to
consider the numerous injuries to which the fcetus is exposed during the
course of delivery. The majority of these occur in connection with pelvic
presentations, especially where pelvic contraction is present in the same
patient. Wherever labour is obstructed by abnormal conditions of the fcetus
or of the pelvis the delicate tissues of the foetus are liable to suffer injury.

In breech presentations, injury to the vessels and soft parts about the
groin and damage to the external genital organs may result from traction
with the fillet and blunt hook. Haemorrhage into the liver, spleen, or
around the kidneys may be caused by forcible traction on trunk. Fracture
of femur or humerus may be due to attempts to bring down a leg or arm.
Fracture of clavicle may arise from the same cause. Bruising of the muscles
of the spine and back of the neck from traction on the legs and over the

LABOUR, ACCIDENTAL COMPLICATIONS 275

shoulders. Hemorrhage into the sterno-mastoid muscle is also caused by
traction over shoulders. Injury to the articulation of the lower jaw from
traction by means of the finger on the lower jaw. Dislocations are rare.

In face presentations, damage to the eyes may result from want of care
in making a vaginal examination. Injury to the muscles and soft structures
of the neck may be caused by extraction with forceps in mento-posterior
positions.

In vertex presentations, bruising and haemorrhage into the brain or
beneath the dura mater may result from difficult forceps deliveries. Fracture
of the cranial bones may be produced by precipitate labour. In cases of con-
tracted pelvis, grooving and indentations of the scalp and cranial bones may
be seen with or without haemorrhage beneath the pericranium or within the
skull. Paralysis of the facial nerve may be due to forceps delivery in vertex
presentations. The paralysis usually disappears shortly after labour.

Still-birth. — By still-birth is understood that condition in which the child
after birth does not show the ordinary signs of life, but at the same time
the signs of life may return either permanently or for a time if suitable
treatment is employed. Cases in which intra-uterine death has occurred
during pregnancy from various causes are not included under this title.
Under normal circumstances, at the moment of birth the foetus enjoys a
condition of apnoea. Very soon — within a minute or two — a sense of want
of oxygen is experienced, which acts as a stimulus to the medullary centre,
and respiratory movements are initiated. The alteration in the surrounding
medium may also act as a peripheral stimulus to the respiratory centre in
the medulla. Any condition which interferes with the supply of oxygen to
the foetus during labour, and anything that prevents the entrance of air into
the lungs, when the pulmonary circulation is established after the birth of
the child, causes asphyxia to supervene, and the child is then said to be
still-born. The onset of asphyxia is accompanied by expansion of the thorax,
with opening up of the pulmonary circulation in the foetus ; this is followed
by the inspiration of any media which happen to surround the child at the
time. If it occurs while the head still lies in the cavity of the pelvis, even
though it may be possible for some air to find its way into the lungs, liquor
amnii mixed with mucus, hairs, etc., may be drawn into the lungs, and oxy-
genation of the foetal blood will be interfered with. With the opening up
of the pulmonary circulation, less blood passes along the umbilical arteries
to the placenta, and as a consequence the centres in the medulla become
less well supplied with blood, and their irritability is diminished. The
respiratory movements gradually cease, and asphyxia results. In other
cases asphyxia is caused by prolonged pressure on the head, frequently pro-
duced by forceps, causing injury to the centres in the medulla, or causing
haemorrhages into the brain or beneath the dura mater.

The causes of still-birth comprise, 1st, those conditions in which the
supply of oxygenated blood, from the mother to the foetus is interfered
with ; among these may be mentioned pressure on the cord in breech pre-
sentations, where the after-coming head is delayed, and compression of the
cord, where it is prolapsed or coiled round the foetus ; 2nd, those cases in
which the mother's condition' during labour becomes very grave, either as
a result of severe ante-partum haemorrhage, eclamptic convulsions occurring
during labour, or exhaustion of the mother from prolonged labour; 3rd,
those cases in which there is direct injury to the centres in the brain from
prolonged pressure, as in cases of forceps delivery in case of difficult vertex
presentations, or in case of prolonged traction where the after-coming head
is delayed.

276

LABOUB, EETENTION OF PLACENTA

The signs of still-birth depend on the degree of asphyxia. For the
characteristic signs and special treatment of asphyxia livida and pallida
the reader is referred to the special article on this subject, "Artificial
Bespiration," vol. i.

Retention of Placenta

Definition . . . .276
Simple Eetention in Uterus . 277
Morbid Adhesion oe Placenta 277
Spasmodic Contraction of
Uterus 278

Retention in a Fibroid Uterus 279
Retention of Fragments . 279

Retention in Cervix or Vagina 279
Method of Removal . .280

Definition. — When the placenta is not discharged from the genital canal
within a certain period following the birth of the child it is said to be
retained. The duration of the third stage of labour is, however, subject to
such wide variations in normal cases that any definition of " retention "
must of necessity be more or less arbitrary. From the Strasburg Maternity
100 cases have recently been reported in which the separation and expul-
sion of the placenta were left entirely to nature, and in 44 of these cases
the third stage occupied an hour or less; in only 80 cases was it con-
cluded within three hours ; in the remaining 20 cases it occupied various
longer periods up to twelve hours. Ahlfeld states that if the expulsion
of the placenta is left entirely to nature in only 5 to 8 cases per 1000 does
retention occur. Strictly speaking, retention of the placenta ought there-
fore to be a rare complication of labour. The tendency of modern practice,
however, is, and has been for some time, to shorten the natural duration
of the third stage by assisting the expulsion of the placenta by compression
and manipulation of the uterus, while, if the placenta is not delivered
within an hour, the case is regarded as one requiring more active interference
on the part of the medical attendant. Eetention of the placenta as thus
understood has consequently become one of the most frequent complications
of labour with which we have to deal. But it should be clearly understood
that delay is the only fault in a large number of such cases.

Varieties. — There are two stages in the normal process of expulsion of
the placenta : A, its separation from the uterine wall and passage into the
lower uterine segment and cervix ; B, its expulsion from the body through
the vagina and vulva. In cases left entirely to nature it is found that
stage A (stage of separation) seldom occupies more than fifteen to twenty
minutes ; while stage B (stage of expulsion) is usually very much longer.
It follows from this that a retained placenta may lie, A, in the uterine
cavity (i.e. above the retraction ring) ; B, in the lower uterine segment and
cervix, or in the vagina. Since the expulsion stage is naturally much
longer than the separation stage, it follows that the placenta will be
oftener found retained in the cervix or vagina than in the uterus. The cause
of retention in the uterus is always non-separation of the placenta, either
complete or partial ; the causes of retention in the cervix or vagina are (1)
non-separation of the membranes, (2) deficiency of the expulsive forces.
The frequency of the two varieties (A and B) is in inverse ratio to their im-
portance ; retention in the uterus is relatively rare, but of major importance ;
retention in the vagina is relatively frequent, but of minor importance.

A. Retention in the Uterus ; Eetention with Non-separation
either complete or partial. — This is due to some hitch in the normal pro-
cess of separation of the placenta. As a rule either uterine contraction and re-

LABOUR, RETENTION OF PLACENTA 277

traction are incomplete, or they are unable to effect separation owing to
the abnormal firmness of the placental attachments. The former is well
designated " simple retention in the uterus," and is dependent upon some
degree of uterine inertia ; the latter is the condition known as " morbid
adhesion of the placenta." These two are the commonest varieties of reten-
tion of the placenta in the uterus. A much rarer variety is that dependent
upon spasmodic contraction of the uterus, or, as it is usually called, " hour-
glass contraction." In this curious condition there are two factors — (1) non-
separation (complete or partial) of the placenta ; (2) spasmodic closure of
the lower part of the uterine cavity. Another rare condition is retention
in the uterus from the mechanical obstacle offered by a fibroid tumour
occupying the lower part of the uterine cavity. These four varieties of
retention in the uterus must now be noticed in detail.

I. Simple Retention in the Uterus. — This condition is not truly
pathological at all ; the placenta would probably, in all such cases, be ex-
pelled spontaneously if only sufficient time were allowed. As already
stated, however, modern practice authorises the removal of the placenta by
artificial means if its delivery is delayed beyond an hour; hence the
frequency of simple retention. Cases are recorded where the placenta has
been expelled spontaneously several days, or even a week, after the birth
of the child, without any untoward result to the mother. Two clear risks
attend prolonged retention — (1) the risk of haemorrhage ; (2) the risk of
decomposition of the placental tissue. As long as the placenta remains
completely undetached there will be no haemorrhage, because no uterine
vessel has been laid open. Should any part, however, become detached,
serious bleeding may occur from the denuded part of the uterine wall, and
interference may become urgently required at very short notice. Decom-
position of the placental tissue would not occur if atmospheric organisms
could be rigidly excluded from the genital tract, but as this is impracticable,
dead organic matter in the uterine cavity is rightly regarded as a source of
grave danger. On the other hand, manual removal of the placenta under
antiseptic methods introduces no additional risk, while at the same time
it relieves the patient from the dangers mentioned. Non-appearance of
the placenta within an hour after the birth of the child is therefore an
indication for interference on the part of the medical attendant. If there
is unusual bleeding, the placenta has been partially detached ; if not, the
placental attachments have been undisturbed. Serious haemorrhage is,
however, unusual in this form of retention. On passing the fingers into
the uterine cavity the detachment of the placenta can be effected with great
ease, and herein lies the diagnostic distinction between this form of reten-
tion and that next to be described.

II. Morbid Adhesion of the Placenta. — It is obvious that the patho-
logical lesion which determines this condition must lie in the stratum
through which the line of cleavage passes in the normal process of separa-
tion, i.e. in the ampullary layer of the decidua serotina. It is a fact not
very creditable to obstetrics that the precise nature of these changes has
never been determined. The question can only be profitably studied in the
placenta in situ, i.e. before the morbid attachments have been destroyed,
and of course opportunities of obtaining a uterus with an undetached
adherent placenta must be extremely rare. It is easy to surmise that an
inflammatory process attacks the serotina, rendering it thicker, denser, and
tougher than usual, but there is no actual evidence that such a change
ever occurs in the decidua, and it is better to admit that the causes are
entirely unknown. The morbid condition, whatever it may be, rarely

278 LABOUE, PRETENTION OF PLACENTA

involves the entire placenta ; some portion of it is usually separated by the
normal process, while the affected part remains attached. The result is
that smart haemorrhage occurs from the stripped part of the placental site,
although at the same time the uterus may feel hard and firmly retracted.
While the placenta remains wholly or partly in the uterine cavity complete
retraction is impossible, and for the closure of the uterine sinuses it is
essential that complete retraction should occur. "We find this condition is
usually indicated, therefore, by haemorrhage, while the uterus remains large
and is fairly well retracted ; it is thus readily distinguished from haemorrhage
due to uterine inertia. Haemorrhage is almost invariable with morbid
adhesion of the placenta, because the adhesion is practically never universal,
but affects portions of the placenta only. If universal adhesion be present
there is, of course, no haemorrhage. Neither is there external bleeding in the
rare cases in which the circumference of the placenta is adherent while the
central part becomes detached ; a large retro-placental haematoma may then
be formed. Sometimes the membranes as well as the placenta are adherent.

The diagnosis of this condition depends upon the recognition by the
fingers of the morbid adhesions. Eirm, dense bands and strings are found
uniting the placenta with the uterus ; these usually have to be torn through
with the fingers or finger-nails, as they are so firmly united to the uterine
wall. Sometimes portions of placental tissue cannot be removed at
all, and must be left to break down and become discharged with the
lochia. Cases have been recorded (Morgagni, Tarnier) where scissors have
been required to cut through bands of unusual strength.

The treatment is to remove the placenta without delay. The method
of removing the retained placenta will be dealt with in the last paragraph
of this article.

III. Spasmodic Contraction of the Uterus. — The absurd and meaning-
less name which is still usually applied to this condition is " hour-glass
contraction of the uterus," a name supposed to indicate the peculiar
alteration in the shape of the organ which was supposed to be induced by
it. The original diagrams are still faithfully copied into obstetric text-
books, although they represent, not the condition actually found, but the
theory by which their author sought to account for what he found. It
is essentially a deviation from the normal processes of retraction and con-
traction of the uterine muscle which obtain during the third stage of
labour. A transverse zone of spasmodic contraction occurs, usually just
above the retraction ring, which narrows the cavity so much that it may be
impossible to pass the finger through it, and the cord may be tightly
gripped. Very rarely the entire organ is affected, and the whole uterus so
firmly closed that nothing can enter it, even under anaesthesia. Eeliable
observers have stated that sometimes the cervix itself becomes closed by
spasmodic contraction, but this appears to be rare, and is primd facie
improbable. More commonly a transverse zone is alone affected ; the
placenta lies above it, and may be separated by the normal process of
retraction in the uterus above the zone of spasm. Its expulsion is, however,
prevented by the narrowing of the canal, and free bleeding consequently
occurs. The condition is not usually recognised by abdominal examination,
but on passing the fingers through the cervix they encounter the obstruc-
tion formed by the narrowed part of the uterine cavity. Sometimes a
portion of the placenta is caught in the constriction, and the cord can
always be felt passing through it.

Of the causes of this condition nothing is known. It is certainly not
due, as was once supposed, to the exhibition of ergot during labour, for in

LABOUK, EETENTION OF PLACENTA 279

most of thejrecorded cases no ergot had been previously given. Ahlt'eld is
probably right in regarding it as due to irritability of the uterine muscle
when more or less exhausted by labour, and he considers that too early and
too vigorous attempts to express the placenta are the commonest exciting
cause.

The treatment is to dilate the constriction and remove the placenta if
the amount of bleeding is serious ; if there is little or no bleeding the uterus
may be allowed a few hours' rest, when the spasm will pass away, and the
placenta will then probably be spontaneously expelled. Usually the amount
of bleeding is too great to allow of the expectant treatment being adopted.
Even under anaesthesia great difficulty may be experienced in dilating the
constriction, and the removal of the placenta may have to be effected piece-
meal, as only one or two fingers can be passed up to the fundus. Once the
placenta is removed the uterus usually retracts firmly, and there is no more
haemorrhage.

IV. Retention in a Fibroid Uterus. — -An interesting example of
this rare condition has been recorded by Dr. Haultain,1 in which, after a
miscarriage, the placenta was retained, and all attempts to remove it failed
owing to the insuperable obstacle offered by a fibroid in the lower uterine
segment. It had to be left, and the patient died of septicaemia from
placental decomposition.

Ketention of Fragments of Placenta or Membrane. — If a small
portion only of a placenta is morbidly adherent, while the attachments of
the remainder are healthy, the non-adherent part may be expelled by the
uterine contractions, leaving the adherent part in situ. Occasionally the
entire chorion may be thus left in the uterus, being torn off round the
placental margin ; the amnion generally goes with the placenta, as it is much
tougher than the chorion, and less firmly united to that membrane than
to the umbilical cord. Portions of the chorion may be thus retained.
The decidua is so thin and friable that it is probably seldom expelled entire,
but its retention is of no importance. Outlying portions of placental
tissue {placenta succenturiata) when present are, of course, often retained
either by morbid adhesion or simple non-detachment.

Diagnosis. — If the portion of retained placenta or membrane be not
very large, and if in addition uterine contraction and retraction are
efficient, there may be no immediate haemorrhage, and the fact of their
retention may then be overlooked. Later on in the puerperium more or less
severe secondary haemorrhage will occur during their separation. A minute
examination of the whole after-birth ought always to reveal the occurrence
of retention of fragments ; this is comparatively easily seen in the case of
a portion of the placenta, but not so easy if a succenturiate placenta or
a piece of chorion be retained. Excessive bleeding from a contracted
uterus after the delivery of the after-birth depends either upon lacerations
or upon retention of fragments, but only by passing the fingers into the
uterus can it be definitely settled that there are retained portions present.

Treatment. — Ptetained placental fragments must always be sought for
at once and removed ; in the case of the chorion, the subsequent risks —
secondary haemorrhage and decomposition of lochia — are much less. Small
fragments of chorion may therefore be allowed to remain, but if a piece of
any considerable size be retained, it should be sought for and removed in
like manner.

B. Eetention in the Cervix or Vagina ; Pretention of a Detached
Placenta. — This condition is very frequent, and of comparatively little
1 Allbutt and Playfair, System of Gynaecology, p. 592.

280 LABOUK, EETENTION OF PLACENTA

importance, as it does not occasion much haemorrhage. It may be due to
deficiency of the expulsive forces, when expression suffices to deliver it, or it

may be duo to morbid adhesion of the

■ " membranes (Fig. 56), when digital

removal is called for. The fact that

the placenta is not retained in the

uterus may be noticed by observing

the size and position of the uterine

§ ■ body. When the placenta leaves it

"j, «^_W -£wM an obvious diminution occurs in its

size, while, as Varnier has pointed out,

the level of the fundus often rises a

little when the placenta lies below it,

thus preventing the uterus from sink-

^»^* -.- - • m£' mto the pelvis (see Figs, on pages

*V^ 149, 150)- If the condition be not

\A *-i recognised on abdominal examination,

%\H : ,, ; the finger passed into the vagina will

0e~ at once feel the placenta bulging

iJsW pi ,;,?;■ through the external os, or perhaps

lying free in the vaginal canal.

, ;t- Method of removing a Placenta

: M-.„i'_Jl .- ■ retained in the Uterus. — When the

-■■-^sf 4m fingers must, for any reason, be passed

pg S I i'^&jM m^° tne Parturient uterus, the strictest

■/jfTjJ^ antiseptic precautions are required;

1 I - & ;• ''■■}* / it is unnecessary to enumerate them

ra£&- .-Ik?* fj2 t . here, the reader will find them set

forth in the section on the management
of labour. In removing an undetached
placenta, the natural process should,
as far as possible, be closely followed ;
i.e. first, the placenta should be com-
pletely detached from the uterine wall ;

Fig. 56.-DU, adherent decidua ; Oi, os internum ; and, Second, it should be expressed Or

aSSK^vSg^Sif*™004^' withdrawn from the body Unless

detachment is completed before the
removal of the organ is begun, fragments or larger portions of placental
tissue will remain attached, and the complete evacuation of the uterus thus
rendered more difficult.

The entire hand having been passed into the vagina under anaesthesia,
the fingers first seek the lower edge of the placenta, and if no abnormality
exists in the placental attachments, these are very readily torn through by
sweeping the finger between the placenta and the uterine wall. One hand
upon the uterus steadies it while the fingers gradually pass upwards to the
fundus or across it, where the opposite placental edge is reached. Outlying
lateral portions have then to be dealt with, and not until it is clear that the
placenta lies quite free in the uterine cavity should its removal be com-
menced. It may then be withdrawn by the fingers into the vagina, or
preferably the hand may be removed and the placenta delivered by
expression. It is not necessary, in most cases, to detach the membranes
with the fingers ; they are peeled off when the placenta passes into the
vagina, just as in the natural process of delivery of the after-birth.

Difficulty in detaching the placenta may arise from morbid adhesions at

LABOUR, POST-PARTUM HAEMORRHAGE

281

the placental site, or from constriction of the lower part of the uterine cavity-
due to muscular spasm or to an encroaching fibroid tumour. Morbid
adhesions can generally be broken through with the aid of the finger-nail,
but much time and patience may be required for the task. Cutting instru-
ments, such as scissors or the curette, should not be employed ; it is better
to leave small portions of placental tissue in the uterus than to run the
risk of injuring the uterine wall. Adherent membrane may be even more
troublesome than adherent placenta, but, fortunately, there is less risk in
leaving it. Constrictions often cause very great difficulty, as it is unsafe to
use any form of mechanical dilator.

Fig. 57. — Method of detachment.

A good deal of bleeding always attends the artificial separation of the
placenta, because retraction is impeded by the fact that the fingers as well
as the whole placenta are in the uterine cavity during the process.
When the cavity is completely evacuated retraction usually follows, and the
bleeding then ceases. A hot antiseptic intra-uterine douche should always
be given afterwards, and massage practised through the abdominal wall,
till all relaxation of the uterus has been overcome.

Post-partum Haemorrhage x

Primary Post-partum Hemor-
rhage . . . • . . 282
Varieties . . . .282
Traumatic Hemorrhage . .282
Varieties .... 282
External Traumatic Hemor-
rhage 282

Internal Traumatic Hemor-
rhage ..... 283

Atonic Hemorrhage . . 285

Concealed Post-partum Hemor-
rhage ..... 290

Secondary Post-partum Hemor-
rhage . . ... . 290

post-hemorrhagic collapse . 291

1 For accidental and unavoidable haemorrhage during labour, see ' ' Pregnancy, Haemor-
rhage during."

282 LABOUE, POST-PAKTUM H^MOEEHAGE

I. Primary Post-partum Hemorrhage

Primary post-partum haemorrhage is the term applied to haemorrhage
occurring at any time within six hours after the birth of the child. It is
one of the commonest accidents met with in midwifery. It occurs in two
distinct varieties : —

A. Traumatic haemorrhage.

B. Atonic haemorrhage.

Traumatic Hemorrhage

Traumatic haemorrhage is the term applied to haemorrhage due to lacera-
tion of any part of the genital tract, the result of direct or indirect violence.
Bleeding due to rupture of the uterus is not, however, included under this
head, as in the majority of cases of rupture haemorrhage is only one of several
symptoms, and consequently is better dealt with under the head of Eupture
of the Uterus.

Varieties. — Two varieties of traumatic haemorrhage are met with : —

1. External traumatic haemorrhage.

2. Internal traumatic haemorrhage.

1. External Traumatic Hemorrhage. — External traumatic haemor-
rhage, in which the blood escapes externally, is very much the more common
of the two forms.

^Etiology. — External haemorrhage may result from lacerations occurring
about the clitoris, perinaeum, or cervix, during the expulsion of the child.
Perinaeal lacerations very rarely bleed to an extent sufficient to justify the
name of haemorrhage.

Symptoms. — The symptom of the case is haemorrhage of a varying
degree, which is not affected by the contractions of the uterus.

Diagnosis. — External traumatic haemorrhage has to be distinguished
from atonic haemorrhage, that is, from haemorrhage due to failure of the
uterus to contract. Practically, we find that as a rule we commence to
treat all cases as if they were atonic haemorrhage, and that it is owing to
various points which are determined during this treatment that we make
the diagnosis of traumatic haemorrhage. The first of these points is that
the bleeding is found to be unaffected by the contractions of the uterus ; the
patient bleeding as rapidly when the uterus is contracted as when it is lax.
The second is that while we are douching out the vagina or uterus with a
double -channel catheter — Bozemann's — we notice that though blood is
coming from the vulva, the fluid which is returning through the catheter is
colourless. If the haemorrhage is comins: from a laceration of the clitoris or
perinaeum, this latter fact is noticed when the nozzle of the catheter is in
the vagina ; if from the cervix, when the nozzle is in the uterus. As soon
as we have in this manner roughly localised the site of the haemorrhage, by
carefully examining it the exact bleeding spot can be found.

Treatment. — If the haemorrhage is found to come from a laceration of
the clitoris, the easiest and most effective method of checking it is to pass a
silk suture deeply below both ends of the laceration with a small curved
needle. These sutures, which may if necessary be passed right down to the
bone, are then tied tightly, and as a rule the haemorrhage immediately
ceases. If the tear is of great length, a third suture may be passed between
the other two. These sutures are removed on the eighth day. Occasionally
bleeding follows their removal, but if so, it can always be checked by
means of a firm compress applied for a few hours.

LABOUR, rOST-rARTUM HAEMORRHAGE 283

If the haemorrhage is coming from the perinaeum, it will be checked by
the ordinary sutures which are inserted to bring together the lacerated
perineal body.

Haemorrhage coming from a cervical laceration is the most troublesome
to check on account of the difficulty of exposing the laceration. If we have
an American bullet-forceps or any form of volsella at hand, the cervix is drawn
down by means of them. If, however, as frequently happens, we have not
a volsella, an extemporised form of cervical tractor can be made in the
following manner. Thread a small curved needle with a long ligature of
number eight or ten silk. Pass two fingers of the left hand into the vagina
to touch the most prominent portion of the cervix. Introduce the needle —
held in a needle-holder — into the vagina under cover of the fingers of the
left hand, and pass it through the cervix. The ends of the ligature are then
knotted together, and by traction upon them the cervix can be exposed.
The descent of the cervix will be very much facilitated by firm supra-pubic
pressure upon the fundus. As soon as the source of the haemorrhage has
been exposed, the latter is checked either by the ligation of a spouting
vessel or by the suturing of a laceration. If the site of the haemorrhage
cannot be found, the bleeding can be stopped by plugging the utero-vaginal
canal with iodoform gauze. Cervical sutures are to be removed on the
eighth day, unless they have also been inserted with the object of bringing
together the edges of a laceration. In such a case they may be left in situ
until the fourteenth day.

Prognosis. — The prognosis of external traumatic haemorrhage is always
good unless the case is either neglected or improperly treated. It is
especially bad in cases of low insertion of the placenta, owing to the
proximity of the uterine sinuses to the laceration.

2. Internal Tkaumatic Hemorrhage. — Internal traumatic haemor-
rhage is the term applied to traumatic haemorrhage in which the blood
instead of escaping externally flows into the peri-vaginal or peri-vulvar
tissues. If this occurs, a haematoma forms of varying size, and from this
the condition has been given the name of hematoma vel thrombus vagince et
vulvce. It is said to be one of the rarest accidents in midwifery.

Frequency. — Internal traumatic haemorrhage sufficient in amount to
require treatment is a very rare occurrence. Statistics of its relative
frequency are difficult to obtain. Winckel estimates its frequency at 1 in
1000, Hugenberger at 11 in 14,000. At the Rotunda Hospital there were
six cases in 13,549 deliveries.

JEtiology. — The direct cause of the condition is the rupture of a vein in
the tissue beneath the lowest part of the vaginal wall, more rarely beneath
the vulvar mucous membrane (Winckel). The cause of the rupture is to be
sometimes found in great stretching of the vaginal walls, especially when
very rapidly accomplished, in the existence of vulvo-vaginal varices, or as
the result of subsequent sloughing of the coats of a blood-vessel the_ result
of long-continued pressure. However, in the majority of cases of this con-
dition no assignable cause can be found. In such cases the rupture of the
vessel may have been due to a pre-existing abnormal thinness of its coats,
or to the gliding of the vaginal wall as it is drawn upwards during labour
over the deeper structures, a gliding which may be associated with lacera-
tion of a vessel (Perret). A strong predisposing element to rupture, which
is present in all labours, is the obstruction to the venous return which
occurs during the descent of the head, and which tends to produce thinning
of the walls of the veins by over-distension.

Pathological Anatomy. — These haemorrhages may occur either below or

284 LABOUE, POST-PARTUM H^EMOEEHAGE

above the pelvic diaphragm, and consequently can be divided into infra-
fascial and supra-fascial. Infra-fascial haematoniata usually form, as has
been said, at one or other side of the lower portion of the vaginal canal. If
they form externally they are most frequently situated in the labia majora,
more rarely in the labia minora, or in the remains of the hymen or perinaeum.
Usually a well-defined tumour results varying in size from that of a hen's
egg to that of a foetal head. In some cases the haemorrhage may extend in
all directions, surround the whole vulva and vagina, and extend downwards
upon the thighs. Sometimes, as the result of perforation of the pelvic fascia
from sloughing, such haemorrhage may extend upwards, as in supra-fascial
haematoniata. Primary supra-fascial haematomata are very rare. If a vessel
ruptures in this region blood may collect round the upper part of the vagina,
and then extend upwards in all directions beneath the peritoneum, reaching
the kidneys behind, the level of the umbilicus in front, and the iliac crests
laterally.

Symptoms. — A haematoma may form during delivery, but, as will readily
be understood, although the vessel may be torn prior to the expulsion of the
child, the pressure of the head will most usually prevent the escape of blood
until after that event. Whether the child has been expelled or not, the first
symptom of the condition is intense pain, associated with swelling in the
neighbourhood of the ruptured vessel. In a short time a small tumour forms,
elastic to the touch and of a blue colour, and gradually increases in size. If
the haemorrhage continues and the case is not treated, this tumour may
rupture and the bleeding become external. At the same time, the patient
becomes collapsed and anaemic in proportion to the amount of blood lost.

Terminations. — Internal traumatic haemorrhage, if allowed to remain
untreated, may terminate in one of the following ways : —

(1) The tumour may rupture, and free external haemorrhage result which
may or may not prove fatal.

(2) The haemorrhage may extend interstitially — upwards towards the
abdomen, or downwards towards the perinaeum — according as the ruptured
vessel is above or below the pelvic fascia. The patient may thus bleed to
death into her subcutaneous tissue.

(3) The tumour if small may be absorbed aseptically.

(4) Suppuration or decomposition of the contents of the tumour may occur.
Treatment. — If the condition is recognised before the birth of the child

the latter should be delivered immediately. If the amount of effused
blood is still small, the forceps can be applied in the ordinary manner. If,
however, the size of the tumour is so great as to obstruct delivery, its walls
must be incised, its contents turned out, a piece of iodoform gauze placed
over the opening, and the child delivered as quickly as possible. If
the tumour has not been incised, and it increases slowly in size after
delivery, the effects of firm pressure upon it may be tried. If this fails, or
if the increase in size has been very rapid, it will be necessary to incise its
wall and turn out the contents. In any case in which incision is practised,
and the cavity is of large size, the latter should be douched out and then
firmly plugged with iodoform gauze. This plugging is changed every day
until the cavity is obliterated. If the latter was found to be of small size
on opening it, deep sutures passed beneath it, so as to bring its walls together
when they are tied, will be found to be as satisfactory as and less trouble-
some treatment than the plug.

If the tumour is of small size it may be left to absorb. Suppuration should
never occur. If it does, the abscess must be opened at the spot at which it
points, the pus evacuated, and the cavity plugged with iodoform gauze.

LABOUE, POST-PARTUM HAEMORRHAGE 285

Prognosis. — The prognosis depends upon the treatment adopted and on
the situation of the haemorrhage. Supra-fascial bleeding is very much more
dangerous than is infra-fasoial, on account of the difficulty of checking it if
it does not cease of its own accord. In either case the patient may die of
haemorrhage or sepsis. In the common form of hematoma neither should
occur if the case is properly treated.

Atonic H^emokehage

Atonic post-partum haemorrhage is the term applied to haemorrhage due
to the failure of the uterus to contract. Loss of blood occurs to a very
slight extent in almost all cases of labour, as it is impossible for the placenta
to be detached and expelled without such an occurrence. It is only when
the amount lost becomes excessive that the term post-partum haemorrhage
can be applied to it. The average amount of blood lost, taking clots and
fluid blood together, is four ounces before the placenta is delivered, and six
ounces with the placenta and membranes (Dakin). According to Winckel,
as soon as the patient has lost from 400 to 500 grams (fourteen to seventeen
ounces) of blood, active treatment with the object of preventing further loss
must be commenced.

Frequency. — The frequency of atonic post-partum haemorrhage depends
entirely upon what amount of haemorrhage we consider can be called post-
partum haemorrhage. In the Rotunda Hospital amongst 13,549 confinements
there were 167 which required some form of treatment more radical than the
massage of the fundus and the administration of ergot, that is, one case in
8P13. Amongst these a few cases of traumatic haemorrhage are included.

JEtiology. — Before starting to discuss the causes of atonic post-partum
haemorrhage it is well to understand the factors which normally prevent its
occurrence, as by so doing its aetiology will be rendered more obvious. The
haemorrhage which occurs during the detachment and expulsion of the
placenta is normally checked by the united action of three factors : —

(1) The Contraction of the Muscular Coat of the Uterus. — The contrac-
tions of the muscular coat of the uterus bring about a temporary cessation of
haemorrhage during their occurrence. Each fibre of the uterus diminishes
in length, and as a result the whole organ becomes almost as firm and hard as
a billiard ball, and all the supplying arteries are compressed. As soon as the
contraction passes off, and it only lasts a very short time, the uterine
fibres return to their original length, the compression of the vessels ceases,
and the haemorrhage would recommence if another factor quite distinct
from, but in a manner dependent on the contraction was not also occurring.
This factor, which is the most potent agent in causing the permanent cessa-
tion of the haemorrhage, is the retraction of the uterine muscle fibres.

(2) The Retraction of the Uterine Muscle Fibres. — By the retraction of
the uterine muscle fibres is meant a process which implies a permanent change
in the relationship of the fibres to one another. During every contraction
not only does each fibre shorten, but it becomes drawn upwards a very minute
distance towards the fundus, i.e. it retracts. As a consequence fibres which
at the commencement of a contraction were end to end, at the completion
of the contraction may have their ends overlapping one another, and after
a few more contractions may have come to lie parallel. This new position
of the muscle fibre, brought about by its gradual retraction, is a persistent
position. It brings about the progressive diminution in size of the uterus,
which is required to suit the diminution in the uterine contents as the
foetus is expelled during labour ; and, after delivery, it brings about a final

286 LABOUK, POST-PAETUM H^EMOBBHAGE

reduction in size, which is sufficiently marked to cause a permanent kinking
and compression of the placental vessels. Accordingly, retraction is the
process to which the final and permanent checking of haemorrhage is due,
but it must also be remembered that retraction itself is due to the occurrence
of contraction. Contraction alone is not sufficient to check hsemorrhage
permanently, but it is the means by which a permanent check is provided.

(3) The Clotting which occurs in the Mouths of the Vessels. — The clot-
ting which occurs in the mouths of the vessels is so unimportant a factor in
the checking of hsemorrhage that it may be almost neglected. It may be
the direct cause of the cessation of hsemorrhage in a few very small vessels,
but it will probably be more correct to consider its occurrence as being the
result of the hsemorrhage ceasing rather than as a cause of its doing so.

The above are the normal agencies by which the occurrence of post-
partum hsemorrhage is prevented. Accordingly, we are now in a better
position to understand what are the conditions which will favour the
occurrence of hsemorrhage. Speaking generally, the latter may be said to
be anything which tends to prevent the due retraction of the uterine
muscle fibres, either directly as a retained adherent placenta, or indirectly,
by preventing contraction from taking place, as degeneration of the fibres
from some pathological condition.

The following are the principal causes of post-partum hsemorrhage : —

(1) Retained Placental Fragments, Membranes, or Blood-Clots. — Such a
condition is generally due to bad management of the third stage. Fragments
of placenta and membranes may, however, also be retained owing to their too
firm adhesion to the uterine wall, the result of a former endometritis.

(2) Uterine Inertia. — This may in turn be due to : — (a) Previous over-
distension of the uterus, as in hydramnios, twins ; (b) Metritis ; (c) Pro-
longed labour ; (d) Weak muscular development of the uterus ; (e) Faulty
shape of the uterus — mal-development ; (/) Tumours.

(3) Precipitate Labour. — During a precipitate labour the uterus has not
had time to undergo the normal amount of retraction, and consequently is
not ready — so to speak — for the third stage.

(4) Placenta Prsevia. — In this condition the hsemorrhage results from a
portion of the placenta being attached to the non-contractile lower ut'erine
segment.

(5) Tumours of the Uterus. — These, as well as causing uterine inertia,
act by preventing the uniform retraction of the fibres.

(6) Any Condition which weakens the Patient. — Such are : — (a) Previous
haemorrhages ; (&) Any form of wasting disease.

Diagnosis. — The diagnosis of atonic hsemorrhage is made by finding
hsemorrhage coming from the interior of a non-contracted or badly con-
tracted uterus.

Treatment. — The treatment of post-partum hsemorrhage falls under two
headings : —

(i.) Prophylactic Treatment,
(ii.) Curative Treatment.

(i.) Prophylactic Treatment. — The prophylactic treatment of atonic
hsemorrhage consists in the proper management of the third stage. The
writer considers this to be a point of so great importance that he offers no
apologies for giving a brief account of it in this place.

As soon as the child is born the patient is turned upon her back, and
the doctor or nurse " controls " the fundus with one hand. To do this, the
hand is placed horizontally over the fundus of the uterus with its ulnar
border sunk down into the abdomen so as to touch the promontory of the

LABOUR, POST-PARTUM HEMORRHAGE 287

sacrum. It is thus in a position to note the occurrence or cessation of
uterine contractions, and during the latter to prevent the accumulation of
blood in the cavity by exerting firm pressure when necessary. If the bladder
is full it ought to be emptied, as pressure over a distended bladder causes pain,
and also makes the future expression of the placenta more difficult. Nothing
further is done, if everything progresses in a normal manner, until the
placenta has left the contractile part of the uterus. As soon as this occurs the
placenta is expressed from the vagina by the " Dublin method," or, as it is
more commonly, though incorrectly, termed, Crede's method. As the placenta
passes through the vulva it is seized in the hands and gently rotated, so as
to twist the membranes into a rope, and thus bring them away entire.
Any slight haemorrhage which may occur is checked by massage of the fundus
and the administration of ergot. As soon as it has ceased the binder is
firmly applied; and, until the last pin which fastens it is in process of
insertion, the controlling hand should remain upon the fundus.

If the third stage is correctly managed, the frequency of post-partum
haemorrhage is reduced to a minimum. It is said that the number of cases
of this form of haemorrhage which occur in a doctor's practice are in
inverse proportion to the skill with which he manages this critical period.

(ii.) Curative Treatment. — The curative treatment of post-partum
haemorrhage is most satisfactory, if it is intelligently carried out. It is
essential to have a definite plan of action laid down in our minds which we
know so thoroughly that we shall follow it mechanically. Such a plan
should be graduated so as to commence with the mildest measures, and then
pass on — if they fail — to others which will be more radical. The following
is such a plan in the order that should be adopted, and presupposing that
the failure of each measure in turn requires the adoption of the subsequent
one :—

(1) If haemorrhage starts after the birth of the child which is not checked
by massage of the fundus, ascertain whether the placenta is in the uterus or
vagina. The signs which tell us that the placenta has left the uterus
are: —

(a) The lengthening of the portion of cord which is outside the vulva.

(&) The rising of the fundus upwards from a finger-breadth or two above
the pelvic brim almost to the umbilicus.

If the placenta is in the uterus, try the effects of massage for a little
longer. If this does not check the bleeding, or if the placenta was already
in the vagina —

(2) Express it by the Dublin method, if possible. To express the placenta,
grasp the fundus with one or both hands during a pain, and press it down-
wards and backwards in the direction of the last piece of the sacrum. By
this means the uterus is displaced downwards into the vagina, and the
placenta driven out in front of it. Then stimulate the fundus to contract
by friction and the administration of ergot. Up to three drachms of the
liquid extract of ergot may be given by the mouth, but more certain and
rapid in its action is the hypodermic administration of citrate of ergotinin.
From Jq- to -Jg- of a grain of the latter may be injected. If this still fails to
check the bleeding, or if the placenta could not be expressed at the start —

(3) Place the patient in a cross-bed position, wash her externally, and
douche the vagina with a solution of creolin (§ss. to a gallon), at a temperature
of 110° to 120° E., having first passed a catheter, if this has not been done
already. If the placenta is still in the uterus, remove it manually. The

288 LABOUE, POST-PAETUM ILEMOEEHAGE

removal of a placenta is a comparatively simple operation as far as the
operator is concerned, but it is by no means as straightforward for the
patient. In the first place, it is rarely if ever possible to give an anaesthetic,
and consequently the operation is attended with a considerable amount of
pain. In the next place, it is an operation during the performance of
which it is specially easy to inoculate the patient with septic infection,
owing to the intimate relationship of the fingers to the uterine sinuses,
while detaching the placenta. It is performed as follows : — The preliminary
steps as described above having been carried out, the hand is introduced
into the uterus, taking care to keep outside the membranes, at the
same time applying firm counter-pressure over the fundus with the other
hand. Feel for the edge of the placenta, and then with a to and fro sawing
motion of the fingers separate it from the uterine wall, gradually working
up from below. Endeavour if possible to detach it in one piece, and then,
grasping it in the hand passed above it, draw it out. Then douche out the
uterus thoroughly, and administer ergot as directed above.

If the placenta has been previously removed by expression, and the
vaginal douche fails to check the haemorrhage, a hot uterine douche is given,
creolin solution being used as before. If the bleeding still continues —

(4) Compress the fundus firmly between the fingers of one hand in the
anterior fornix and the other hand upon the abdominal wall, thus squeez-
ing out any clots that may be retained, and then repeat the intra-uterine
douche.

(5) Introduce the hand into the uterus and remove any fragments of
placenta or of membranes, and all clots. Then repeat the intra-uterine
douche.

(6) In those cases in which haemorrhage resists the above treatment,
there are still two final measures before us from which a choice can be
made. These are, either to plug the utero-vaginal canal with iodoform
gauze, or to inject perchloride of iron into the uterine cavity. Of the two,
the former is preferable, as will be seen later.

The uterus is plugged with iodoform gauze in the following manner : —
Place the patient in the cross-bed position, if she is not already in it, and seize
the anterior lip of the cervix with an American forceps and the posterior lip
with another. If a short posterior speculum is to hand it may be introduced,
and will facilitate the proceeding. It is not, however, absolutely necessary.
Then pass the end of a long strip of iodoform gauze, about two inches in
width, up to the fundus, by means of a special plugging forceps or with the
end of the Bozemann's catheter. The remainder of the strip is pushed up
piece by piece until it is finished. A fresh strip is then knotted on to the
former, and introduced in a similar manner. As soon as the uterus is full
the forceps are removed, and the vagina also plugged. As a rule, three to
four strips of gauze six yards long and about two inches wide are required.
It must be remembered that it is not the large cavity of a dilated uterus
which we have to plug, but rather the comparatively small cavity of a con-
tracting one, because on the introduction of a small piece of gauze the
hitherto flaccid uterus quickly contracts upon the foreign body. Finally, a
tight abdominal binder is applied in order to compress the uterus from
above, and more ergot may be given. The gauze must be removed in from
twelve to twenty- four hours, and if there is any rise of temperature a
uterine douche administered.

The use of perchloride of iron was introduced by Barnes. He recom-
mended that a few ounces of Liq. ferri perchlor. (B.P.) be injected into
the uterine cavity from which all clots have been removed. Another and

LABOUE, POST-PAKTUM ILEMOEEHAGE 289

perhaps easier method of applying the iron is to add Liq. ferri perchlor.
fort. (B.P.) to warm water until a light sherry-coloured fluid is produced.
The uterus is douched out with this and then with ordinary creolin solu-
tion. Barnes claims that iron acts in the following manner : —

(a) It coagulates the blood in the mouths of the vessels.

(b) It constringes the tissues round the mouths of the vessels, and so
compresses the latter.

(c) It provokes some contraction of the muscular wall of the uterus.
The great advantage of iodoform gauze over iron is that it has no

tendency to interfere with the nutrition of the superficial portions of the
uterine wall. Iron, on the other hand, causes a very considerable super-
ficial necrosis, and, if saprophytic germs gain entrance to this dead tissue,
they have a very suitable pabulum on which to live. Again, iodoform
gauze is as certain as anything can be in its action, and even if the haemor-
rhage is coming from a large vessel which has been torn across owing to a
laceration of the uterus, it will in all probability prevent it from bleeding.
Iron may and sometimes does fail, and if it does it is impossible to resort
to plugging as, owing to the manner in which the tissues have become con-
stringed, gauze could not be introduced. If iron is used, the uterus must
be douched out next day, and every subsequent day if there is any rise of
temperature.

The above is the line of treatment which the writer considers is most
suitable in cases of atonic post-partum haemorrhage. It, is of course,
impossible to follow a regular stereotyped plan in all cases ; special cases
call for special variations in the treatment, and in some instances it may
be necessary to resort immediately to the plug owing to the condition of
the patient. However, in the great majority of cases in which the accou-
cheur has been in attendance from the commencement of the haemorrhage, it
will be possible to follow a system such as the above, and so save the patient
from the risk of intra-uterine manipulations in all but the most serious
cases.

There are two proceedings which are very frequently recommended that
have not been mentioned. They are of use in some cases, and if they will
not finally check the haemorrhage they will at all events gain a little time.
The first of these is compression of the aorta. It is comparatively easy —
unless the patient is very stout or strains very hard — to compress the aorta
through the abdominal wall against the lumbar portion of the spinal column.
It is a proceeding which is of use, if we have an assistant capable of per-
forming it, while preparations are being made for intra-uterine treatment.
The second proceeding is the bimanual compression of the uterus, not as
recommended above with the object of expressing clots, but rather with the
object of preventing further haemorrhage by compressing the bleeding
vessels. It is carried out as follows : — Pass the right hand into the vagina
and place two fingers behind the cervix in the posterior fornix. With these
fingers press the cervix forwards in such a manner as to fold it beneath the
body of the uterus. Then compress the latter as firmly as possible between
the vaginal hand and the left hand upon the abdominal wall. This is also
only of use in order to gain time, as it will rarely if ever arrest the haemor-
rhage finally. As such, however, it may sometimes be found of use.

There are a few methods of treatment which the author would like to
warn against. Such are the intra uterine injection of vinegar, the freedom
of which from bacteria can never be assumed ; the application of ice or the
pouring of cold water on the patient's abdomen, a practice which is suffi-
cient to determine the death of a collapsed patient by increasing the

VOL. VI 19

290 LABOUK, POST-PAETUM ILEMOKKHAGE

collapse ; the introduction of ice into the uterus, both on account of the
risk of sepsis and of the shock it causes ; the injection of ergot before the
placenta has left the uterus, unless we are prepared to remove it immedi-
ately ; and the plugging of the uterine cavity with any material which is
not absolutely sterile.

Prognosis. — The prognosis of post-partum haemorrhage is always good if
the case is taken in time. A woman can lose an amount of blood immedi-
ately after delivery without being very much affected, which at another
time would bring her to the point of death.

Concealed Post-paktum Haemorrhage. — Concealed post-partum
haemorrhage is the term applied to post-partum haemorrhage when the
escaped blood is stored up in the uterus instead of pouring out through the
vulva. It is to a large extent an artificial condition, that is to say, it is
caused by the attendant compressing the lower uterine segment instead of
the fundus, and so placing an obstruction in the way of the escape of the
blood. It may also occur behind a detached placenta which is blocking
the lower uterine segment, if the fundus is not properly controlled. If it
occurs it is recognised by the increase in size of the uterus. Its treatment
consists in immediately removing the obstruction to the escape of blood
and then emptying the uterus by expression. If the haemorrhage still con-
tinues, the further treatment of the case is the same as that of the more
usual form of post-partum haemorrhage.

II. Secondary Post-partum Hemorrhage

Secondary post-partum haemorrhage is the term applied to bleeding
coming on more than six hours after the completion of labour. It is also
known as puerperal or late haemorrhage.

Frequency. — At the Eotunda Hospital, in which patients remain for
eight days after their confinement, thirteen cases of secondary haemorrhage
occurred in 13,549 confinements, a proportion of one in 1042-23.

JEtiology. — Secondary post-partum haemorrhage may arise in three
ways : —

(1) Owing to the separation of the thrombi in the mouths of the uterine
blood-vessels. This may occur owing to some sudden increase in the blood-
pressure, or to the sloughing of the coats of a vessel as a result of a previous
long-continued pressure.

(2) Owing to a congested condition of the endometrium. The commonest
cause of congestion of the endometrium during the puerperium is a relaxed
condition of the uterus. This condition, which is known as subinvolution,
may be caused by the retention of pieces of placenta or membrane, mal-
positions of the uterus, faecal accumulations, or getting up too soon.

(3) Owing to the presence of tumours, either pre-existing or arising
subsequent to delivery. Amongst pre-existing tumours, myomata of the
body of the uterus are the commonest. The only tumour which is likely to
form subsequent to delivery is that known as deciduoma malignum (vide
article " Puerperium ").

Treatment. — If the haemorrhage is slight, the administration of ergot in
full doses, the expression of all clots from the uterus, and absolute rest in
bed, may be sufficient to check it. If it does not respond to this treatment,
or if it is severe from the start, the vagina and uterus should be douched
out with hot creolin lotion, and the latter explored with the fingers in order
to ascertain the cause of the haemorrhage. If a retro-deviation of the uterus
is present it must be corrected, and a pessary inserted if the uterus will not

LABOUE, POST-PAETUM ILEMORKHAGE 291

remain in a normal position of its own accord. If a portion of placenta has
been left behind it must be removed with the finger or blunt curette. If
haemorrhage still continues, the uterine cavity must be plugged with iodo-
form gauze. In addition the bowels must be regulated, and the daily
administration of ergot continued for some days. If the haemorrhage is due
to the presence of a myoma, and the bleeding cannot be checked by the use
of ergot, hot douches, and plugging, it may be necessary to discuss the
advisability of hysterectomy or myomectomy, according to the situation of
the tumour. If the latter is pedunculated it can, of course, be easily removed.
Indeed, this should be done in all cases as soon as the condition is recognised,
as the risk of such a tumour sloughing after delivery is very considerable.
Deciduoma malignum admits of but one treatment — immediate and com-
plete hysterectomy.

Post -hemorrhagic Collapse. — -The very favourable results which
attend the early recognition and treatment of post-haeniorrhagic collapse are
so marked that it is deemed advisable to devote a separate paragraph to this
condition.

Symptoms. — The symptoms of collapse due to excessive loss of blood are
most characteristic. At first there is no noticeable change in the condition
of the patient save a slight increase in the frequency of the heart. As the
haemorrhage continues this becomes more marked, and the pulse at the same
time becomes small and feeble. Gradually, the aspect of the patient becomes
blanched, the conjunctivae especially being of a pearly white, respiration is
more hurried, and the patient frequently sighs. This condition, which is
known as air-hunger, is the result of the lessened amount of oxygen which
the diminished blood-stream carries to the tissues and the medulla ob-
longata. If the temperature is taken, it is found to have fallen from one to
three degrees. As the haemorrhage continues, the above symptoms become
more marked. The pulse becomes uncountable and finally imperceptible,
and the body is covered by a cold sweat. Hurried respiration is replaced by
dyspnoea, and the patient, struggling for breath, requests to be raised as high
as possible. If this is done she probably loses consciousness momentarily,
or the sudden elevation of the head may be even sufficient to cause the
final failure of the heart. She gradually becomes more and more restless,
complains of inability to see, and finally becomes comatose, with perhaps
occasional convulsive movements.

Treatment. — When a patient loses a large quantity of blood death
threatens. This occurs, not because there is an insufficient quantity of
blood in the body, but because the blood-vessels have not as yet had time
to suit their capacity to the diminished amount of fluid which they now
contain. As a matter of fact, a woman greatly collapsed from post-partum
haemorrhage is said to have as many red blood corpuscles in her body as an
anaemic girl. In consequence of the unfilled condition of the vessels, blood
does not return to the heart in sufficient quantities ; the latter has nothing
to contract upon ; as a result its contractions become more and more feeble,
and an insufficient quantity of blood is sent to the brain. In consequence
of the resulting anaemia of the brain feeble stimuli are transmitted to the
heart, which fails still more, a vicious circle being thus established. Eeason-
ing from this we see that, to successfully combat the tendency to cardiac
failure, our treatment must be directed towards three points : —

(1) The heart must be directly stimulated. Direct stimulation of the
heart can be performed by the administration of alcohol by the mouth ; by
the hypodermic injection of ether, strychnine, or brandy; by the rectal
injection of brandy or coffee ; and by the use of hot fomentations over the

292 LABOUK, POST-PARTUM ILEMOEEHAGE

precordial area. In administering alcohol by the mouth, we must be careful
not to give it in such large quantities as to cause vomiting. Half an ounce
may be given at first of a mixture of one part of whisky or brandy in two
parts of water, followed by a teaspoonful of the same every five or ten
minutes. From twenty minims to a drachm of ether may be injected
hypodermically, and from ^T to ■£$ of a grain of sulphate of strychnine.
Several syringefuls of brandy may be used instead of ether ; the latter is,
however, preferable. From half an ounce to an ounce of brandy or whisky,
mixed with from four to eight ounces of strong, hot coffee, may be injected
into the rectum.

(2) The diminished quantity of blood must be limited as far as possible to
the vital organs of the body, i.e. the brain and viscera. This is a most
important point, and one which is frequently forgotten during the carrying
out of the necessary measures for checking the haemorrhage. The even
momentary diminution in the amount of blood which is going to the brain,
due to some sudden elevation of the patient's head, may prove fatal. While the
patient is in the cross-bed position all pillows must be removed from beneath
her head, and if her condition is serious the limbs must be tightly bandaged
from below upwards, in order to drive the blood from them to the more
important parts of the body. So soon as the bleeding has been checked,
and the patient has been returned to bed, the bottom of the latter must be
raised from six inches to a foot by placing bricks or other sufficiently firm
support beneath the legs. Subsequently, as the patient improves the
bandages may be removed, and the foot of the bed brought gradually back
to its former level.

(3) The amount of fluid in the blood-vessels must be increased. The
amount of fluid in the blood-vessels can be increased in the following ways : —
by administering abundance of fluid by the mouth ; by rectal injections of
salt and water ; by infusing saline solution directly into a vein, or into the
subcutaneous connective tissue. As thirst is always present to a marked
degree in these cases, it is never difficult to get the patient to drink large
quantities of fluid as soon as she has rallied somewhat from her collapse. It
is not, however, a method of increasing the fluid in the body which can be
adopted at first, as sufficient quantities to have any effect in this direction
would almost certainly cause vomiting. Eectal injections of saline solution
of the same strength as that infused into a vein (06 per cent, roughly a
teaspoonful of salt to a pint of water) will be absorbed most quickly. From
one to two pints may be given, and it must be injected very slowly, as
otherwise the patient will not retain it. The difficulty of retention of the
fluid is often hard to overcome, and consequently in urgent cases one or
other of the two remaining proceedings is usually adopted.

Direct intravenous infusion of saline solution is the most rapid method
of increasing the amount of fluid in the blood-vessels. It is a course of
procedure which, while it has many supporters, has also a number of
opponents on the grounds of its danger and uselessness. If it is carefully
carried out, the risk attending it is by no means great, while doubts with
regard to its usefulness are most probably due to the fact that it is suffering
at present from the results of previous over-estimation. Intravenous in-
fusion will not bring a patient who is in the last stage of collapse from
hsemorrhage back to life, but, if it is performed before this stage is reached,
it will in all probability prevent her from even falling into such a condition.
To render the proceeding of use, a sufficient quantity of fluid at a proper
temperature must be infused. The necessary amount will vary between
three and six or even eight pints. JSTo definite quantity can be fixed which

LABOUR, POST-PAETUM HAEMORRHAGE 293

will suit all cases, but the infusion must be continued until there is a
marked increase in the volume and strength of the pulse. The solution is
used at a temperature of 100° to 102° F. In order that the proceeding may-
be as free from danger as possible, everything used in the operation must
be sterile, and due precautions must be taken to prevent the entrance of air
along with the fluid. The apparatus used consists of the following : — A
glass or metal funnel capable of holding at least two ounces ; a rubber tube
of about three feet in length ; a small silver or white metal cannula with a
blunt point ; and a scalpel, dissecting forceps, small needles, needle-holder,
and fine silk. The operation is performed as follows : — Tie a bandage round
the upper arm sufficiently tightly to compress the veins but not the arteries.
By this means the veins below the bandage stand out sufficiently to be seen,
and a suitable one can be selected. Expose the latter by means of an
incision about an inch in length made directly over it, isolate a small
portion of it, and slip two silk ligatures beneath it ; the distal ligature is
tied to prevent haemorrhage. A longitudinal incision of sufficient length
to admit the tip of the cannula is made in the vein, and the cannula is in-
troduced, care being taken that it is filled with saline solution. Next tie
with a single knot the proximal ligature in such a manner as to compress
the vein against the cannula, in order to prevent the escape of fluid, and
remove the bandage which was compressing the arm. Before the cannula
is introduced the entire apparatus must be filled with saline solution, its
escape being prevented by pressure upon the tube. The fluid is now allowed
to flow, an assistant taking care that the funnel is always full, and that no
air gains admission. By holding the funnel from 10 to 18 inches above
the patient, a sufficient pressure is obtained. As soon as the required
quantity of fluid has been infused the cannula is removed, the vein cut
across, the second ligature tied tightly, and the skin wound closed with
sutures.

Infusion into the cellular tissue has been substituted by many for intra-
venous infusion on account of the greater ease with which it is carried out.
Kelly, who prefers it to all other means of infusion, injects the fluid into
the sub-mammary cellular tissue. For this purpose he uses graduated bottles
capable of holding a couple of pints to which a tube 6 feet in length is
connected. A long, slender, and sharp aspirating needle is fastened to the
other end of the tube. The solution used, is the same as for intravenous
infusion, and a head of 6 feet is required to make the fluid run. To perform
the operation, the breast after careful disinfection is seized in the hand and
lifted as far off the chest wall as possible. The needle, with the saline
solution flowing, is then passed through the skin at the base of the breast
and deeply into the connective tissue, taking care to keep clear of the gland
structure. The fluid then runs in of its own accord, and as soon as no more
will flow the needle is withdrawn. A piece of adhesive plaster fastened
over the opening will prevent its subsequent escape. The breast will hold
from a pint and a half to two pints, and the time required to infuse this
amount is about twenty minutes. A similar amount can be infused under
the other breast at the same time if necessary. Instead of the breast the
fluid may be infused into the connective tissue of the buttock, but the
former site is preferable.

The above is a short description of the immediate treatment necessary
in post-hsemorrhagic collapse. It must not, however, be thought that, as
soon as the patient has rallied, all danger is at an end. The resultant en-
feebling of the circulation carries in its train many dangers from which she
cannot be regarded as safe for a considerable time. The most common of

294 LABOUE, INJUKIES TO THE GENEEATIVE OEGANS

these is cardiac syncope coming on at any attempt at exertion. Pulmonary
embolism may also occur, due to the detachment of a thrombus whose
formation has been favoured by the weak action of the heart. Crural
phlegmasia may occur from a like cause, and, as happens in all debilitating
conditions of the patient, the natural resistance of the system to septic
invasion is so lowered that the risk of infection is greatly increased. In
consequence of the tendency to cardiac failure, the patient must not be
allowed even to sit up in bed during the first week or so, and all attempts
at raising herself must be strictly forbidden. The process of getting up
must be a most gradual one, and even after she is able to walk about all
sudden or violent exertion must be carefully guarded against. In order to
promote her convalescence the administration of iron in tolerably large
doses will be found of considerable benefit. Careful attention to the dietary
and the judicious use of stimulants are also matters of, perhaps, vital
importance.

LITERATURE. — Norms. American Text-book of Obstetrics. — Winckel. Text-book of
Midwifery. — Dakin. Handbook of Midwifery. — Herman. Difficult Labour. — Duhrssen.
A Manual of Obstetric Practice. — Henri Varnier. Obstetrique Joumaliere, Paris 1900. See
also Literature, p. 312.

Injuries to the Generative Organs during Labour

A. Lacerations during Labour—

Position of Injuries .

302

1. RUPTURE OF THE UTERUS

Prophylaxis

302

Causation

295

Treatment

302

Position of Rent

295

Varieties ....

296

5. Injuries to the Perineum-

Evidences ....

296

Varieties .

303

Diagnosis

296

Causation

304

Prognosis

297

Results

304

Prophylaxis

297

Prophylaxis

304

Treatment

297

Treatment

305

2. Laceration of the Cervix

6. Injuries to the Pelvic

Uteri (Infra - vaginal por-
tion) .....
3. Laceration of the Vagina-

299

Articulations .

308

7. Injuries to the Externai

Causation

300

Organs of Generation —

Position of Bent

301

Laceration

309

Evidences

301

Vulva Hcematoma

309

Dangers ....

301

B. Injuries the Result of Pro-

Treatment

301

longed Pressure —

4. Injuries to the Pelvic

Floqr —

Sloughing

310

Anatomy ....

301

C. Acute Inversion of Uterus .

311

Although injuries to the genital tract during labour are actually more
common in multiparse, they occur more frequently in prirniparse when the
cause is pelvic obstruction, or rapid labour, for the passages are being
dilated for the first time. This is especially the case when the obstruction
is in the soft parts, and the " pains " are strong.

The consideration of the subject will be discussed under two main
heads, viz. : —

A. Lacerations and injuries during labour.

B. Sloughing, due to crushing or to prolonged pressure during labour.

LABOUR, INJURIES TO THE GENERATIVE ORGANS 295

A. Lacerations duking Labour

1. Rupture of Uterus. — This accident is said to occur about once in
3000 cases.

Causation. — (a) Predisposing Causes. — Previous operations on the
uterus, involving discontinuity of the uterine muscle fibres. Irregularities
of the pelvic walls, such as bony ridges on the sacral promontory, near the
pectineal eminences, or prominent ischial spines.

(5) Direct Causes. — (1) Rapid labour, especially in primiparse.

(2) Prolonged, especially obstructed labour, such as occurs with con-
tracted pelves, pelvic tumours, cervical or vaginal constrictions, or where
there are foetal malpresentations or deformities. In obstructed labour,
when tonic contraction of the uterus is being produced, the course of events
is as follows : —

The muscles of the fundal zone and of the body of the uterus are acting
vigorously, and the lower zone and cervix, relaxed by the process of polarity,
are being drawn up, stretched over the presenting part, and getting con-
stantly thinner. Bandl's ring, the lower limit of the retraction area, not felt
at all in normal labours, is becoming more and more marked, and after a
time can be felt some fingers' breadth above the pubes by the external
hand. The " pains " gradually lose their intermittency, and a cramp-like
continuity of pain is established, and all the local and constitutional
evidences of tonic contraction of the uterus, already described in the
article on " Precipitate and Prolonged Labour," p. 210 et seq., are observed.
It is this thinned-out portion of the uterus which may rupture. Under
such circumstances, version, or other inappropriate operation, may cause
rupture.

In such cases ergot greatly increases the risk of rupture, for it tends to
cause continuous uterine action, and tonic contraction is more speedily
produced.

(3) Direct Violence. — Instances have been recorded of women being
kicked or run over, or tossed by bulls, with resulting rupture of the uterus.

(4) Criminal Attempts at Abortion. — In such cases the uterus is more
usually perforated than incised or lacerated.

(5) Spontaneous Rupture. — This somewhat obscure accident may occur
as early as the eighth or tenth week from the rupture of an " interstitial "
gestation, but need not be further detailed here, nor need much be said of
those very rare cases of spontaneous rupture, stated to have occurred in the
later months, before any evidence of labour |has appeared, and which are
impossible to explain by merely assuming fatty or other degeneration. A
possible explanation of such cases is that the uterus had been some time
previously operated on, e.g. " rapidly " dilated, and that partial rupture had
then occurred, with subsequent union by cicatricial unyielding tissue. The
author knows of one case where a woman died suddenly at the beginning
of labour who a year previously had the inverted cornu of the uterus
removed unintentionally by the wire ecraseur during the removal of a
fibroid polypus.

Position- of the Rent in Ruptured Uterus. — The rent is usually in the
lower zone of the uterus, and posteriorly and to the left. The line of
laceration is at right angles to the direction of greatest tension, and may
therefore be either longitudinal or transverse, but is usually obliquely
longitudinal, and as such likely to extend through the cervix into the vagina.
If the cervix is nipped between the head and the pelvic brim the lower
segment of the uterus will give way first, but if the cervix be drawn up,

296 LABOUE, INJUEIES TO THE GENEEATIVE OEGANS

as usually occurs, the rupture may begin in the cervix, and may, unless it is
a transverse one, extend downwards to the vagina, or upwards into the
uterine lower segment.

Varieties of Rupture. — If the rupture is " complete," i.e. through all the
coats and covers of the uterus, the peritoneal cavity is generally opened up
posteriorly. If the tear is oblique or lateral, the cellular tissue of the
broad ligament may be opened up, or, if the rent is anterior, the base of the
bladder may be torn, in either case without the peritoneum being reached.
In " incomplete " ruptures, where the peritoneal investment is not torn, it
may nevertheless be extensively stripped off from the uterine muscle, and
the sac thus formed may be distended by blood, by the placenta, or even by
parts of the foetus itself.

Action of the Uterus after Rupture of the Lower Segment. — If empty, the
uterus would contract as firmly down as if its contents had been normally
evacuated, and its size would be that of the normal uterus at the end of the
third stage.

Symptoms and Signs. — Occasionally rupture occurs without any pre-
monitory symptoms having been noticed, owing to absence of skilled obser-
vation. As a rule, however, if rupture be imminent, the " pains," previously
intermittent, will have become continuous, and will be felt mainly in the
lower abdomen owing to the continuous tension of the uterine muscles and
ligaments. There will be constitutional and local evidences of tonic uterine
contraction, with Bandl's ring well marked below the navel. When
rupture has occurred there will be sudden pain and collapse following an
ordinary "pain," if intermittency was still present. There is usually
internal haemorrhage, and, unless the presenting part filled the passage, some
would also escape per vaginam. The presenting part may be felt to have
receded, or to have totally disappeared, but, if foetal impaction had occurred,
no difference would be noticed. In " complete " rupture both the child and
placenta might be in the peritoneal cavity. If rupture had taken place
over an after-coming head, it might not be at first suspected, especially if
the patient were anaesthetised, and might only be discovered when the hand
was inserted to remove what appeared to be a retained placenta. More
rarely the child escapes into the peritoneal cavity at the moment of rupture,
and the placenta is subsequently normally expelled. If the rent is " in-
complete," the child may have partially escaped from the uterus into a sac
formed by the stripped-off peritoneum. In " complete " rents the bowels
may protrude into the vagina, or even appear externally.

Diagnosis of " Complete " Rupture. — In the event of being suddenly
called to a patient suffering from sudden collapse during labour, the dia-
gnosis has to be made mainly between ruptured uterus and concealed acci-
dental haemorrhage. The distinction is, however, obvious, for whilst the
aspect of the patient, the severe and prolonged shock, the evidences of
internal haemorrhage and the recession of the presentation, may be common
to both disasters, the occurrence of the collapse in the second stage of labour,
and the small size of the retracted uterus, point strongly to ruptured uterus
and away from concealed accidental haemorrhage, where the collapse
occurs before or during the first stage, and the uterus is over-distended and
tense. If in addition the child is felt to be outside the retracted uterus, or
if the rent can be felt per vaginam, the diagnosis of rupture is certain.

The diagnosis of " incomplete " rupture is often impossible, and may
not be suspected before delivery, and would then only be known by the
passage of the hand into the uterus, and the detection of the partly stripped-
off peritoneum, or the formation of a sub-peritoneal or broad ligament

LABOUR, INJURIES TO THE GENERATIVE ORGANS 297

hematoma. If the placenta or a portion of the foetus lies outside the
uterus in the sac thus formed, the shock would approximate to the severe
shock of " complete " rupture, and that accident would be suspected.

Prognosis. — In all cases, probably 60 per cent of the mothers die either
from shock or haemorrhage, or at a later stage from septicaemia, and at least
90 per cent of the children.

Prophylaxis. — Whenever possible, the accoucheur should satisfy himself
that any woman wishing to be attended by him at her approaching
confinement has not a contracted pelvis. If a cursory abdominal examina-
tion and a manual palpation of the pelvic crests do not satisfy him,
precise external and internal measurements should be made, and if pelvic
contraction be discovered, labour should be prematurely induced at the
appropriate date. If not seen till " in labour," examine early, and rectify
any malpresentation promptly, and deal at once with any obstruction by
version, perforation, decapitation, or by other indicated operation. If tonic
contraction be present, avoid giving ergot or attempting version, but at
once evacuate the uterus by forceps, or perforation if the head presents, or
by decapitation if the lie is transverse. Rupture may be said to occur
almost always in cases in which the earlier significance of the physical signs
has not been observed or appreciated.

Treatment. — (1.) When the rupture is "incomplete" and there is not
much stripping off of the peritoneum, antiseptic drainage per vaginam is
usually all that is required.

Drainage should be effected as follows : First carefully wash the ex-
ternal genitals, and gently douche the vagina and the lower end of the rent
(the peritoneum being unopened), taking care to allow all the injection to
return at once. Drainage may be adopted by means of iodoform (10 p.c.)
gauze, or by india-rubber tubing. If tubing is used it should be stitched
to the lower end of the rent, but as a rule, gauze, lightly packed into the
rent and allowed to loosely fill the vagina and appear at the outlet, is the
best drain. It may be possible to suture the vaginal part of the rent if
the tear has extended downwards. The gauze may be left in for as long as a
week, if the temperature shows that drainage is effectual. If the tempera-
ture rises, remove the drain, syringe out the cavity still remaining, and
drain again. If the bladder be torn, and the accident were at once dis-
covered, an immediate operation might be tried, and a retention catheter
tied in, but as a rule it would be best to await the partial healing and con-
traction of the wound, dealing with it subsequently as a secondary operation
for vesico-vaginal fistula.

(2.) When the Rupture is " Complete." — If the child is born, and the
placenta has escaped into Douglas's pouch, it can usually be easily removed
by the hand, with antiseptic precautions, and the case treated by vaginal
drainage, but if the rent is extensive, or there is evidence of internal
haemorrhage, and the shock already present be not very severe, abdominal
section is indicated. If the child is not already born, and the bulk of it is
evidently in the uterus, attempts may be made to extract by forceps, but if
this fail, knowing that the child is almost certainly dead, the head should
be perforated, or if it be a transverse lie, decapitated, the body being then
extracted by the arm, and the head by digital traction on the mouth if the
pelvis be normal, or by perforation and crushing if contracted. If the child
be in the abdominal cavity, or being partly in the abdominal cavity, is
gripped by the uterus, it should be at once removed by abdominal section.
If the child be already born, or has been delivered by the accoucheur, let the
hand be passed up and the passages carefully examined under ether, so that

298 LABOUE, INJURIES TO THE GENERATIVE ORGANS

the extent and nature of the laceration and the indication for treatment
can be accurately determined upon. In a word, if the rent be very exten-
sive, and haemorrhage is evidently going on, if the child be in the abdominal
cavity, or if the bowels protrude, abdominal section is essential, otherwise, as
Drs. Herman and Herbert Spencer have recently shown, vaginal gauze
drainage is all that is required. The following are the conclusions come
to by Dr. Spencer : —

In the treatment of rupture of the uterus —

(1) Abdominal section is rarely required, and almost solely in cases
where the foetus has passed completely or in great part into the peritoneal
cavity. It should be performed rapidly under local infiltration anaesthesia,
and should be followed by flushing of the peritoneal cavity with normal salt
solution and by suture of the tear, if possible, or, if this be not possible, by
packing the tear with iodoform gauze and draining by the vagina or abdomen.

(2) Abdominal hysterectomy is hardly ever necessary ; when the broad
ligaments are so much damaged as to endanger the vitality of the uterus,
vaginal hysterectomy should be performed.

(3) All incomplete tears implicating the broad ligament, and most com-
plete tears, should be treated by packing the rupture per vaginam with iodo-
form gauze after removing clots and fluid blood.

If the abdomen is opened primarily for the extraction of the child, or
for the arrest of internal haemorrhage, and it is found that the torn surfaces
can be accurately adjusted by suturing, it would be advisable to do so, and
the following rules may be worth noting : —

Suture of Uterine Laceration. — This operation can only be done
thoroughly after abdominal section. Suturing per vaginam, if the tear is
above the vaginal portion of the cervix, is impossible. Let the abdomen be
opened in the mid-line in the usual way, and if the rent is anterior it is at
once seen, and can often be sutured with the uterus in situ. If the tear is
posterior, it is best to turn out the uterus and bring it well forward, so as
to expose the torn surface. Suture the rent as in Caesarean section, using
deep sutures of silk or silk- worm gut, two-thirds of an inch apart, passing
through the peritoneum and muscles, and avoiding (according to present-
day teaching) the decidual lining. Superficial sutures of catgut or silk to
accurately adjust the peritoneum should then be passed between the deep
sutures. If the torn surfaces are not very accurately united, pockets are
left and the suturing will do more harm than good. (See Eig. 62, p. 307.)

There seems no good reason why the decidual lining should not be in-
cluded in the deep sutures, for if it is not included, the decidua gapes, and
allows the uterine secretions to reach the sutures, the danger of which is the
main reason why it is advised that the lining membrane should not be
touched.

When, the tear is fundal or anterior, and the uterus does not need to be
turned out of the wound, the Trendelenburg position is advantageous, as it
keeps the intestines out of the way. If gauze draining per vaginam is
adopted after abdominal section, a strip of gauze should be passed from the
abdomen and drawn down per vaginam to the vulvar outlet. In such cases
the catheter should be used till the gauze is removed.

2. Laceration of the Cervix Uteri — (Infra- vaginal portion). —
Slight unilateral tears (usually on the left side) or bilateral, or even slight
stellate tears, are almost universal in first labours, and being so common
have proved valuable as probable indications of the previous passage from
the uterus of some large body, such as a viable foetus. Such tears hardly
ever produce symptoms, but will of course add to the risk of sepsis if the

LABOUR, INJURIES TO THE GENERATIVE ORGANS 299

lochia should become infected. The more serious cervical rents will now be
considered.

Causation. — Rigidity of the cervical tissue is one cause, and this may be
due to so-called spasm, the result of absence of the normal polarity, or to
the presence of old cicatricial tissue, or to a fibroid in the cervical wall, or to
malignant disease. The lacerations are usually longitudinal, and as a rule
on the left side, but sometimes, in malignant disease, a complete ring of
cervical tissue may be torn off, owing to its extreme friability. If these
conditions are present, or if the rigidity is so marked that there is insuper-
able obstruction, the uterus is apt to give way in its lower zone, and the
cervix might then only be torn secondarily. If the cervical rent be primary,
it may extend outwards into the cellular tissue at the base of the broad
ligament, upwards into the uterus, downwards into the vagina, or forwards
into the bladder.

Obstetrical operations, such as version with forcible extraction, or the
use of forceps when the cervix is undilated, may also cause severe rupture
of the cervix.

Dangers. — If the rent is confined to the infra-vaginal part of the cervix
the danger is small, though troublesome haemorrhage from division, or
partial division, of a branch of the uterine artery may ensue. The risk of
subsequent sepsis is also increased. If the tear extends beyond the cervix
the risk is increased both as regards immediate haemorrhage and subsequent
septic absorption through the wound, producing probably a septic para-
metritis. Subinvolution not infrequently follows cervical tears.

Evidences of Cervical Laceration. — A tear of the cervix without ex-
tension into the uterine body does not produce shock. The evidences, if
any, would be sudden and unexpected progress being made in a somewhat
protracted labour, with subsequent greater rapidity. There might also be
rather smart arterial hsemorrhage immediately after the birth of the child,
often before the placenta is born, whilst the uterus is nicely retracted, showing
that the hseniorrhage is not coming from a relaxed placental site. Careful
vaginal digital examination would reveal the cervical rent, and the hot
blood could be felt coming from the apex of the tear. If a duckbill
speculum were used, and the cervix drawn down by a volsellum forceps, the
exact nature and extent of the tear would be apparent.

Prophylaxis. — A rigid cervix often relaxes after warm water injections,
or after passing up a tampon of cotton-wool soaked in glycerine. This
encourages glandular secretion, and makes the somewhat dry cervix moist.
A physiologically active organ is always in a state of relaxation. Cocaine
is said to enhance the effect of the glycerine by allaying any local
hyperesthesia. Chloral in doses of thirty grains, repeated in an hour, also
encourages relaxation. If a fibroid is present in the cervical tissue it may
be enucleated. If malignant disease be present the question of Cesarean
section must be considered. Cicatricial contractions may need division.
Forceps should never be used during the first stage of labour merely with
the object of shortening its duration. No obstetrical operations should be
attempted, and ergot should never be given until the cervix is fully
dilated, or at all events dilatable. The first stage of labour should not be
interfered with in normal cases, and the membranes should be left intact
till the completion of their functions.

Treatment. — There is no need to suture all tears as a matter of routine,
unless they have extended into the broad ligament, or there be serious
hsemorrhage. If the uterus remains firmly contracted, the hsemorrhage
must be proceeding from some laceration below the retracted portion of the

300 LABOUR, INJURIES TO THE GENERATIVE ORGANS

uterus, and the finger may at once detect the cervical tear, and the
hemorrhage may be arrested by digital pressure, or by a probe or piece of
stick covered with gauze. A hot vaginal injection at 120° F. will induce
thrombosis, and will encourage contraction of the uterine and arterial
muscle, and will thus usually arrest ordinary haemorrhage. If the haemor-
rhage persist, or the tear is found to be of such a nature and extent that
immediate suturing is needed, the patient should be anaesthetised and
placed on her back with the knees drawn up, and kept in position by a
Clover's crutch. The uterus may be depressed from outside, and the
anterior and posterior lips drawn down by Teale's volsellum forceps, which
have blunt teeth and never tear. The cervix can thus be made to protrude
at the vulva. Swab out the vagina and cervix with wool soaked in
corrosive sublimate solution, 1 in 2000, and douche the uterus itself with 1
in 4000. If the bleeding vessel is seen, seize it with Spencer "Wells'
forceps, and tie with fine silk. Then take a rectangular (Fig. 58) or half-
curved needle set in a handle and pass it deeply at the apex of the rent from
without inwards, through both lips of the cervix, so as to include some of the
cellular tissue of the base of the broad ligament and the branch of the

Fig. 58.

uterine artery. Silk-worm gut is the best suture to use. Three or four
sutures may be required for each tear, and may either be cut short, or left
sufficiently long to protrude from the vulva. Septic absorption should be
prevented by antiseptic douches, whether the tear be sutured or not. If
the broad ligament is opened up and haemorrhage is not persisting, some would
prefer to pack the tear with iodoform gauze, but direct suturing is the
better plan if this be practicable. Secondary operation is rarely required
( trachelorrhaphy) unless subinvolution, with marked hypertrophy, adenoma,
or ectropion of the lips is present. The secondary operation has been
very much overdone.

3. Laceration of the Vagina. — Causation. — Tearing may be due to
stretching of the upper end of the vagina, where obstruction is lower down
than the pelvic brim, or where the foetus is hydrocephalic, or where there is
impaction of a transverse or some complex presentation. With a pendulous
abdomen the posterior vaginal wall is greatly stretched and may give way.
Laceration may also be caused by forcible extraction by forceps or version.
Herman states that vaginal laceration from the use of forceps may occur in
five ways, viz. : owing to the forceps themselves adding to the bulk of the
passenger ; or to the blades not lying quite flat and the edges projecting ;
or owing to the curve of the forceps not coinciding with the cephalic curve ;
or because the normal rotation of the head in the pelvis cannot always be
exactly imitated by the accoucheur with the forceps, and because the dilata-
tion of the vagina is necessarily more rapid and less natural than when the
natural forces are alone acting. Matthews Duncan taught that 12 per cent

LABOUE, INJURIES TO THE GENERATIVE ORGANS 301

of primiparse had vaginal laceration, and of course the more elderly the
primipara the greater will be the rigidity of the parts. Vaginal rents may
be secondary to uterine or cervical lacerations.

Position of Laceration. — The lacerations are usually oblique or trans-
verse, and as a rule are posterior or lateral, corresponding to the position of
the child's face. When secondary to a cervical tear, the injury is usually
lateral and obliquely longitudinal ; when secondary to rupture of the
uterus, it is usually posterior and oblique. Douglas's pouch may be
opened, or the bladder may be torn. I have also seen a deep longitudinal
tear on both sides of the floor of the vagina, exposing the sides of the rectum.

Evidences of Vaginal Rupture. — Uncomplicated vaginal lacerations are
rarely recognised, for shock is absent. Haemorrhage may, however, show
that something more than the ordinary slight abrasions and lacerations has
occurred, and digital examination will then reveal the accident.

Bangers. — Apart from haemorrhage, there is the increased risk of
septicaemia from the larger areas for septic absorption, and there is a further
risk of prolapse of the vaginal walls, with cystocele or rectocele, and possibly
uterine prolapse as a secondary phenomenon.

Treatment. — If the foetus has escaped into the peritoneal cavity, which,
though very rare, has been known to occur in uncomplicated vaginal
tears, abdominal section will be required to extract the foetus, but it
would be impossible to suture the vagina from
that side. As a rule, however, the foetus is
either already born, or can be extracted per
vaginam. If the placenta is in Douglas's
pouch it may usually be extracted without
difficulty or increased injury. If the rent is
small, antiseptic douches are all that is ordinarily
required, the rents speedily closing by granula-
tions. If the rent is large and near the outlet,
antiseptic gauze drainage (see " Rupture of
Uterus," p. 297) is good treatment, unless it
is possible to accurately unite the torn surfaces
by means of a Hagedorn's small half-circle
needle with silk-worm gut, as in Fig. 59, or by
a rectangular needle set in a handle (see Fig. 61).
Drainage and antiseptic douching are especially
necessary if the pouch of Douglas, or the
cellular tissue of the broad ligament, is opened
up. The gauze drain should be left in
situ for at least three days.

4. Injueies to the Pelvic Flooe. — Ana-
tomy.— The pelvic floor, bounded externally by
the skin and internally by the peritoneum, consists
of a diaphragm of muscles with coverings derived
from the pelvic fascia, supported from below by
a more superficial series of smaller muscles, fascia, and connective tissue
padding, the whole covered by skin.

The pelvic diaphragm consists of the powerful levatores ani and coccygei
muscles, which practically shut off the pelvic outlet, allowing the rectum
and vagina to pass through, and to be supported by rather intimate fusion
of their muscle elements with those of the diaphragm. These two muscles
constitute a sling, attached to the pubes in front, and sweeping almost
horizontally backwards, embrace the vagina and rectum, and are attached

Fig. 59. — Laceration of the pelvic floor
extending half-way to the rectum,
with sutures properly placed
ready for tying. (Norris.)

302 LABOITE, INJUEIES TO THE GENEEATIVE OEGANS

posteriorly to the coccyx. The levatores ani are attached along both sides
from the back of the pubes, the " white line " of pelvic fascia, the ischial
spines, and lesser sciatic ligaments, and then unite with each other and with
the coccygei muscles along the middle line to complete the diaphragm.
The muscles then curve downwards and inwards to the lower ends of the
vagina and rectum, helping to form the internal sphincter of the latter, and
uniting behind the rectum along the mid-line of the perineum till they
reach the coccyx.

The pelvic fascia divides into two layers along the "white line." The
upper, visceral, or recto-vesical fascia covers the upper surface of the levatores
ani, and is a structure of great value in enabling the pelvic floor to resist
undue intra-abdominal pressure.

The lower layer of the pelvic fascia is the obturator fascia, covering the
obturator internus muscle, and forming the external investment of the
ischio-rectal fossa. A thin sheet is also given off from the pelvic fascia at
the "white line" — the anal fascia — to cover the under surface of the
levatores ani muscles.

The more superficial structures consist of accessory smaller muscles, the
transversi perinei, the bulbo-cavernosi, and the erectores clitoridis, with
the superficial pelvic fascia, continuous with the triangular pubic ligament,
whose two layers fill in the pubic arch, support the urethra, and form an
attachment to the anterior fibres of the levatores ani. The perineum, largely
composed of the above-named structures, will be described later on.

The pelvic floor may be said to be composed of two segments, an anterior
or pubic, and a posterior or sacral, the vaginal cleft being between. In
labour the anterior segment is drawn up, whilst the posterior is forced
down, and is stretched by the presenting part. Injuries, therefore, to the
tissues of the pelvic floor during labour almost always occur in the posterior
segment, which includes part of the perineum and the perineal body, whose
injuries will be hereafter discussed.

Nature and Position of Injuries to the Pelvic Floor. — There is no doubt
that fibres of the levatores ani may be torn or unduly stretched, or their
attachments to bony or ligamentous points loosened. Occasionally it would
seem that the pelvic fascia itself is injured, for the whole pelvic floor lies at
a lower level than before labour, and is more influenced by intra-abdominal
pressure than it should be, moving too freely with inspiration, coughing,
etc. Schatz and Howard Kelly are firm believers in such injuries, but it
must be remembered that although they undoubtedly occur, the fact that
gaps are felt in the levatores ani after labour does not prove injury, for
those muscles run in distinct bundles with spaces between, and these can
sometimes be felt even in prirniparse. ISTo post-mortem proofs of such
lacerations have yet been published.

Prophylaxis. — The efficient treatment of obstructed labour and of too
rapid labour should prevent these injuries.

Treatment. — If injury to the pelvic floor has been diagnosed, the patient
must be kept in bed longer than usual, but if, as would usually happen, the
diagnosis is not made until after some weeks, when secondary symptoms
have arisen, she must be warned against prolonged standing, and against all
occupations which produce downward pressure on the pelvic diaphragm.
Moderate rest, avoidance of constipation, and of tight corsets or abdominal
bands, should be insisted upon, and in some cases a suitable vaginal pessary
may be worn till the pelvic floor is able to take its full part in supporting
the uterus. Such patients often find temporary relief from a bandage with
a perineal pad to support the perineum.

LABOUR, INJURIES TO THE GENEEATIVE ORGANS 30'

0/7"A NAVICULAR
^ levator fascia.-
TJriangutar Lijmft
Ji/fler/icial layer.

up-Pcrinealha'a.

-JFi&

5. Injuries to the Perineum. — Anatomy. — The female perineum in-
cludes the very important " perineal body," which is a portion of the
posterior segment of the pelvis, and its elastic yet resistant properties enable
the recto-vaginal septum to undergo great distension during labour.

The perineal body is triangular in vertical section, and its boundaries
are the posterior wall of the vagina in front, the anterior wall of the rectum
behind, and the integument covering the perineum between the vagina and
anus below. It may roughly be said to extend laterally as far as the ischial
tuberosities.

The structures contained in the perineal body are well seen in Fig. 60,
and consist of fibre of the levatores ani, superficial and deep transversi
perinei, and bulbo-cavernosi, with the
internal and external sphincter ani
muscles, and layers of fascia from the
anal and superficial perineal fascia, and
from the triangular Ligament.

Nature of the Laceration. — In primi-
parae there is almost always a tear through
the hymen, generally a little on one side
of the central line, and often at several
other points round its vaginal attachments.
The main tear in the mid-line extends
into the fossa navicularis, and usually
will pass beyond this and lacerate
the anterior edge of the perineum, the
posterior fourchette. Deep hymeneal FlG. 6o.-sagittai section of the perineal body
tears necessarily pass through the mucous f^Zlfi) its component structures-
membrane and invade the subjacent con-
nective tissue, and, during the process of healing, the pieces of hymen are
separated as small islets, or tubercles, by intervening cicatricial tissue, or
modified mucosa, and are called carunculce myrtiformes ; the presence of
these is evidence of the passage of a large body through the vaginal outlet, and
would usually indicate the passage of a child of at least a viable age and size.

Tears which involve the perineum usually begin as above stated, extend-
ing backwards along the Line of the median raphe through the sphincter and
into the anus, or they may pass along the side of the mid-Line, and follow
the outer edge of the sphincter without actually destroying its integrity.

Varieties. — Perineal rents may be " complete," i.e. lacerating the vaginal
mucous membrane, perineal body, and sphincter ani, so opening the rectum
anteriorly ; or " incomplete," where the vaginal mucous membrane and the
integument with a larger or smaller part of the perineal body has given
way, leaving the rectum intact. More rarely a tear, termed "central,"
occurs, where the rent seems to begin either on the vaginal mucous mem-
brane or on the perineal surface, and extends deeply into the perineal body,
working right through, leaving the sphincter ani and the posterior fourchette
intact. Cases have been described where the child has been born through
this " central " tear, but in the majority of such cases the anterior margin of
the perineum would ultimately give way, and probably the sphincter ani as
well. Still more rarely the perineal body seems to have given way in its
centre, with a resulting perineal hsematonia, which may suppurate a few
days after the child is born.

As an apparent result of the hardening of the skin of the perineum by
bicycling, extensive tears of the deeper structures of the perineum may
occur. The author has seen a very tough perineal skin drawn forward over

304 LABOUR, INJURIES TO THE GENERATIVE ORGANS

the head as it extended from under the pubic arch, and has subsequently
found the skin to have been completely separated from its subjacent
sturctures almost down to the rectum, accompanied by tearing of the
vagina longitudinally, exposing the rectum laterally also.

Causation. — Perineal injuries are commoner in primiparse, especially
after thirty-five years of age, and the more rapid the labour the more likely
is the tear to be severe. A large " passenger," especially a large head, pre-
disposes, especially if the pains are strong. Sometimes the perineum is too
long, for though its average length, from margin of anus to posterior four-
chette, is just over an inch, it may vary from five-eighths of an inch to over
two inches. Rigidity of the parts, the presence of a small sub-pubic angle,
or an altered inclination of the pubes, may lead to severe tears. In a vertex
presentation the tear usually occurs when the suboccipito-frontal diameter
is passing through the outlet, especially when the supra-orbital ridges are
emerging. In unreduced occipito- posterior presentations the perineum
runs a great risk of rupture, for here, instead of the vulvar outlet being
stretched by the circumference of the head when its diameter is the sub-
occipito-frontal (four inches), it has to make room for the head to pass when
its diameter is the occipito-frontal (four and a half inches). Sometimes the
head seems to be passing through normally, and yet a severe rent suddenly
appears, and it is found that the child's hand was applied to its chin, and
that the sharp ridge of the fore-arm had cut the stretched perineum. The
shoulders also are very apt to commence or to increase a perineal tear, and
may convert an " incomplete " tear into a " complete " one.

Results. — If the laceration is superficial, haemorrhage is slight. Unless
accurately sutured, raw surfaces, over which all lochial discharges must pass,
are left, and, quite apart from distinct evidences of septicaemia, it is not
infrequently found that there may be some pyrexia, 100° to 102° F., about
the fourth or fifth day, when the lochia are a little faint in odour, and
probably contain some chemical toxic elements. Pyrexia is usually absent
if the wounds have begun to granulate up, absorption not taking place
readily through granulation tissue.

If the laceration is " complete," incontinence of flatus and faeces is soon
noticed, and the tendency of the sphincter ani, divided anteriorly, to pull
itself and its adjacent structures backwards is soon apparent, the anus
getting nearer the coccyx, and the antero-posterior length of the vulvar
outlet becoming longer. Tbis may produce a distressing sensation of
gaping of the vulva, even permitting air to enter the vagina when the
patient stoops.

If the perineum is severely torn, and no attempt at union is made, the
anterior vaginal wall loses some of its posterior support, and if it is itself
relaxed and stretched, it is apt to prolapse a little, and a cystocele may
ensue. If this prolapse continues, secondary elongation of the supra-vaginal
cervix, or prolapse of the whole uterus may follow, owing to the continuous
dragging action of the cystocele. These secondary phenomena are, of course,
commoner in cases where the vagina or pelvic floor has received injury, but
there can be no doubt that in women obliged to follow laborious occupations
a ruptured perineum is sometimes the starting-point of uterine prolapse.

Prophylaxis. — In ordinary labours with the vertex presenting, the
accoucheur should wait till the occiput is protruding or causing perineal
bulging, and until the nape of the neck is pressing against the arch of the
pubes. Then the perineum should be supported with the palm of the hand,
and the occiput should be urged forward, and at. the same time too rapid
delivery of the head should be prevented. This encouragement of the

LABOUR, INJURIES TO THE GENERATIVE ORGANS 305

occiput to rotate under the symphysis can best be done just as a " pain " is
passing off, before the recession of the head occurs. When the head has
reached the outlet as far as its supra-orbital ridges, recession is less marked,
and then the largest circumference of the head can sometimes be coaxed
through as one "pain" is ceasing, and before the next commences. If,
notwithstanding, the perineum threatens to give way, tell the patient to cry
out, in order to avoid the reflex bearing-down, give chloroform deeply, and
apply pressure on the occiput with both hands to keep the head back if
possible. The best way to exert pressure upon the occiput is to apply the
right hand from the perineal aspect, and the left between the legs from the
vulvar aspect, and let the fingers interdigitate. Even then it is difficult to
exert sufficient resistance.

Episiotomy. — If a tear seem inevitable, the small operation of episiotomy
may be performed. This should be done exactly at the right time, or not at
all. Wait till the supra-orbital ridges are about to be born, and then, if
the perineum is going to give way, a thin, white, very tense line is seen
almost all round the margin of the vulvar orifice. Take a probe-pointed
knife, pass it on its flat, along the child's head, until its point has passed
under this thin white line, about one-third of the distance between the
central line of the perineum and the base of the vestibule. Then gently
turn the handle till the cutting edge of the knife meets the tense line, which
immediately gives way, and a notch is made, which, though afterwards looking
only a quarter of an inch long, gapes to three times that length as the head
is being born. Make a similar notch on the opposite side, and the head will
almost certainly pass through at the next " pain," with very little deepening
of these two notches, and with the perineum saved. Scissors may be used if
preferred. It is best to put a single suture in afterwards, on each side.

Care should be taken that there is no complex presentation present, such
as a hand near the mouth, with a sharp fore-arm to tear the perineum, and
that the posterior shoulder, as it is born, does not deepen or cause laceration.

If the forceps are being used, rapidity of birth can usually be controlled,
and the head can be coaxed over the perineum, and round from under
the pubic arch between the " pains " at the right moment. When the head
is distending the perineum the forceps may be removed, if it is thought that
nature will then effect delivery without accident.

Anaesthesia, to the surgical degree, is very desirable where there is risk
of laceration, and should always be given when any prophylactic manipula-
tions are being adopted.

Treatment. — Immediately the child is born let the perineum be carefully
examined, and let the nurse, and the patient too, if not under anaesthesia,
understand what is being done, so that no charge of carelessness may be
subsequently brought against the accoucheur. This particular charge,
neglect of a torn perineum, is one so frequently brought against medical
men, with a view to damages, that special care should be taken in making
the examination, and if in doubt as to the need of a suture, let the
accoucheur err on the safe side and insert one.

A good time to make the examination is immediately after the birth of
the child, even before the placenta has been expelled, for the patient is
probably still under anaesthesia. It is quite possible to insert (tying them
afterwards) the necessary sutures at this time also, especially if only perineal
sutures are required, for the parts are then somewhat numbed.

Although trifling tears will heal without sutures, if the legs are tied
together, and the wound kept aseptic, all wounds of the perineum, except
those which have merely torn the posterior fourchette, should be at once
VOL. vi 20

306 LABOUE, INJUEIES TO THE GENEEATIVE OEGANS

sutured. The more extensive the tear, especially if the rectum be involved,
the more necessary is it to suture the rent at once, though union will often
take place if the operation is unavoidably postponed for a few hours.

Preparations for the Operation. — Let the patient be kept under anaes-
thesia if it is considered that sutures are needed. For the insertion of
sutures for " incomplete " perineal tears anaesthesia is not essential, for the
only pain is as the needle enters and leaves the skin, and that is often
somewhat numbed at first. Keep the patient in the lithotomy position, by
means of a Clover's crutch or an improvised roller-towel or sheet-sling.
Clean the parts well with antiseptic lotion, and dam back any haemorrhage
coming from the uterus with antiseptic vaginal tampons. Let an assistant
separate the labia well, and expose the torn surfaces. The parts should be
shaved if hirsute.

(1) The Operation for " Incomplete " Rupture. — The best needle is a rect-
angular one fixed in a handle, as recommended by Dr. Cullingworth
(Fig. 61). Pass the sutures in such a way, that when they are tied, the
wound is entirely obliterated without any incurving of the skin or mucous

FULL

SLZE

Fig. 61.

membrane. In introducing the sutures, notice carefully if any spots in
either of the raw surfaces are depressed or cupped. If so, it shows that
muscle-fibres, e.g. of the sphincter ani, are cut through and retracted. These
must be carefully caught in the sutures, and drawn to the surface. The
rectangular needle, unarmed, should enter the skin or mucous membrane
(Fig. 59), quite close to the edge of the tear, should pass deeply into the
tissues under the base of the rent and out at the other side, " buried "
throughout. The needle should then be threaded with silk-worm gut and
withdrawn. The first suture should be inserted opposite the posterior angle
formed by the tear, nearest the anus, and the other stitches, one-third of
an inch apart, should then be inserted anterior to the first one till the
anterior margin of the perineum is reached. After all the sutures have
been inserted they should be tied in the same order. The following
diagrams show the faulty and the correct methods of inserting sutures for
the repair of incomplete ruptures (Figs. 62, 63).

The sutures should be removed in seven days, after the bowels have
been well opened.

(2) The Operation for " Complete " Rupture. — When it is found that the
sphincter is torn, and the rectal mucous membrane exposed, the patient
must be arranged in the lithotomy position, in a good light. The rectal
tear must be sutured first with catgut, the sutures being introduced first at
the apex of the tear, the highest point from the anus. The best way to
insert the sutures is as follows : — Let the rectal wound be put on the stretch
by an assistant's hands, one on each side of the vulva. Steady the apex of

LABOUR, INJURIES TO THE GENERATIVE ORGANS 307

the wound with dressing forceps, and take a rectangular, or, if preferred, a
half-curved needle set in a holder, and pass it, unarmed, from the rectal
aspect at the apex of the tear, as close as possible to the torn surface, at its
very edge, without actually passing through the rectal mucous membrane
itself, and pass it sideways into the tissues in such a way that it includes a
little bunch of submucous and muscular tissue, and comes out again at the
edge of the vaginal mucous membrane without actually entering the vagina
itself. Then thread the needle, the eye of which is at its point, and with-
draw it, leaving the catgut in the track made. Then pass the unarmed

Fig. 62. — A, faulty method of suture, falling short of the bottom of wound and not catching all the muscle-
ends : a, before tying ; b, after tying. The latter figure shows dead space at the bottom of wound after
tying ; perineal body only partially restored. B, suture improperly placed : a, before tying ; 6, after tying.
The suture (a) has too little lateral sweep, and it does not include the ends of all the retracted muscle-fibres
at the sides of the wound ; 6 shows the result, the pelvic floor being imperfectly restored. (Norris.)

Fig. 63. — Shows fall sweep of a properly placed suture : a, before tying ; &, after tying. Even though the tear
runs in different planes at different depths, the muscle-ends are held in apposition throughout the entire
depth of the wound. (Norris.)

needle in a similar manner on the opposite side of the apex of the rent, and
thread it when passed with the vaginal end of the catgut which was left in
the tissues on the opposite side, withdraw it, and tie the catgut suture, so
that its knot is in the rectum. Then pass succeeding sutures from above
downwards, till the anus is reached, tying each before the next is passed.
When tied, each suture may be at once cut short, or, as is found more con-
venient in practice, hold the one just tied in the left hand to steady the
parts till the next suture is introduced and tied, and then cut short the
previous one. If the sphincter ani is only partly cut through, a so-called
purse-string suture, as advised by Dr. Percy Boulton, may be used, either
without inserting any rectal sutures, or in addition to them, to add to their
security. The purse-string silkworm-gut suture is passed completely round

308 LABOUR, INJURIES TO THE GENERATIVE ORGANS

the rectal wound. It is made to enter at the edge of the skin at the anal
end of the tear, and is passed along, buried, parallel with the cut rectal
surface to the apex, and back again along the other side, and out again at
the anal edge of the wound. It should be buried sufficiently deeply at its
first insertion to include the muscle of the divided sphincter (see Fig. 59,
p. 301), for then, when tied, it accurately draws the sphincter forwards, so
that the divided strands are in close contact, and at the same time it affords
great support to the catgut rectal sutures already passed. As a rule it
should be inserted before the rectal catgut sutures are passed, but should
not be tied till afterwards.

6. Injuries to the Pelvic Articulations. — Causation. — The pelvic
joints are the sacro-iliac, the pubic, and the sacro-coccygeal. They are all
united by cartilage, and are rendered more mobile during pregnancy owing
to softening and hypertrophy of the cartilage, with increased development
of the existing synovial pouches. The result is that during labour there is
a yielding of the bones united by these joints, and a certain definite though
inconsiderable gliding motion is permitted. This has been proved by
Walcher, Pinzani, and others, and is the raison d'etre of " Walcher' s position "
in difficult labour. The joints are unduly strained if there is any marked dis-
proportion between the pelvis and the passenger. The pubic joint is neces-
sarily divided in symphysiotomy, but unites promptly with fibrous union,
unless antiseptics have broken down, when suppuration and destruction of the
cartilage would ensue, and bony union eventually would take place. In this
same operation the sacro-iliac joints are liable to be seriously injured if, at
the moment of division of the inter-pubic cartilage, the legs are unsupported
and allowed to fall outwards. The sacro-coccygeal joint is rarely injured,
for it allows of very free movement. If, however, there has been previous
dislocation and fixation of the joint, and especially if the coccygeal apex
points forward, difficulty at the end of the second stage may arise, and
fracture at the joint has been known to take place. More rarely disloca-
tion of the coccyx has been known to occur during labour, the point of the
coccyx then pointing backwards.

Evidences of Injuries to the Pelvic Articulations. — The main evidence of
serious injury to one of the pelvic joints is dyskinesia — difficulty in walking
— associated with local pain and tenderness. If the patient is not seen till
some weeks after labour, the local pain and tenderness will have passed off,
and no evidence may be left except the dyskinesia. To examine the pubic
joint let the patient be placed on her back. A thumb placed in the vagina
and applied to the back of the symphysis, whilst the other fingers of the
same hand are over the joint, will enable intra-pubic mobility or tenderness
to be determined, especially if one leg is passively moved up and down by an
assistant. To examine the sacro-iliac joint the patient should stand, sup-
porting herself against a fixed point, and the physician should apply his
ear to each joint in succession, whilst the patient flexes and extends the
thigh of the same side. If there is much movement in the joint some
creaking or crackling will be heard. In all such cases the effect of a tight
girth round the pelvis, a large towel for instance, is almost diagnostic, for
the patient, who just before wobbled about, unable to walk without support,
can now walk very fairly across the room, experiencing great support and
relief. If the sacro-coccygeal joint is affected, an examination with one
finger in the rectum, and the thumb outside, will enable the physician to
grasp the bone, and judge at once of its mobility, its relations, and the
tenderness of its joint. The main symptoms, at first, if the joint is inflamed,
are coccygodynia (painful sitting), with some dyschezia (painful defsecation),

LABOUR, INJURIES TO THE GENERATIVE ORGANS 309

and often pain when coughing or sneezing, owing to traction on the coccyx
by the muscles of the pelvic floor. After a time all these symptoms, except
coccygodynia, disappear.

Treatment. — If the pubic or sacro-iliac joints are very tender, a blister
will be the best treatment, with rest in bed. Later on, a firm binder round
the pelvis, with avoidance of all exertion, is indicated, and will soon lead to
the joint becoming normal again. If the sacro-coccygeal joint be affected, a
blister often cures ; but, if the coccygodynia persists, or the coccyx is found
fixed and displaced forwards or backwards, it may require to be forcibly
readjusted, or more rarely to be excised.

7. Injuries to the External Organs of Generation. — (a) Laceration
of the Vulva. — Tears through the hymen have already been discussed ; but
tears may also take place in the vestibule, or through the labia minora, or
even extend into the labia majora, or the urethra may occasionally be
injured near its external meatus.

Evidences. — The tears in these cases, unless the swelling of the parts
should prevent, are at once seen on inspection. The haemorrhage, unless
some varicose vein or the venous plexuses in the labia majora are torn across,
is not severe ; but bleeding from a superficial tear in these vascular tissues
may continue for many hours or days, and be overlooked owing to the
presence of the lochia, and may produce profound anaemia.

Treatment. — Any tear should be at once closed with catgut, or silk, to
check haemorrhage, and to ensure primary union.

(b) Vulva Hematoma. — Occasionally a pudendal vein gives way during
the second stage of labour, and if the skin remains intact a vulva haematoma
results. Such an accident usually occurs in priniiparae, because in multi-
paras the veins are more varicose and superficial, and tend to burst ex-
ternally. If a large hseinatoma is formed, obstruction to the presenting
part may result.

Evidences. — The usual symptom is severe pain in one labium majus, felt
suddenly during a "pain," in. the later part of the second stage, and not in-
frequently some shock results. On examination the swelling of the labium
is found to be irreducible, dark in colour, bulging over the labium of the
other side, tense and fluctuating, but gradually getting less elastic as the
blood coagulates, and finally getting boggy from oedema round the effusion.
There is no impulse on coughing. It is distinguished by its history, and
by its physical signs, from distended Bartholini's gland, labial abscess,
hernia, and varicose veins.

Treatment. — If there is definite, though slight, obstruction, and the
head presents, deliver with forceps. If the obstruction is such that forcible
delivery would bruise or tear the swollen parts, the tumour, after the vulva
has been shaved, must be incised on the skin aspect, along the long axis of
the labium. Turn out the clot, and apply pressure till the child is born,
tying any bleeding point. If the wound can be made quite clean and free
from any adhering clot, a few buried purse-string sutures will approxi-
mate the surfaces, and an attempt may be made with outside pressure to
promote primary union. As a rule such cavities do not thus heal, and may
be packed with gauze, and allowed to granulate up.

B. Injuries due to Prolonged Pressure on the Internal
Generative Organs

Causation. — In some cases of obstructed labour there is extensive
nipping of some parts of the uterus, cervix, or vagina, between the head

310 LABOUK, IKJUEIES TO THE GENEBATIVE OEGANS

and some bony point of the pelvis, most commonly the pubic symphysis.
We have seen that obstructed labour often leads to tonic contraction of the
uterus, and subsequently to thinning of the lower zone, and to laceration of
the stretched tissues, but delivery may be effected without laceration, and
yet the tissues, swollen from oedema and hemorrhagic extravasation, lose
their vitality. A slough then forms, and is thrown off in from four to
ten days by a process of ulceration between the dead and living tissue, and
if the slough be deep, it may include the lining membrane of a neighbour-
ing viscus, such as the bladder, and a urinary fistula would result. If, in a
contracted pelvis, the^anterior lip of the cervix is nipped between the head
and the brim, the part below the pressure becomes swollen, and this further
delays labour. The part nipped soon loses its vitality, and eventually
sloughs, and a utero-vesical fistula would result ; or, if the whole anterior
lip of the cervix sloughed, the fistula would practically be a vesico-vaginal
one. In either case some bladder irritation and, possibly, some cystitis
may follow, and some induration from cellulitis may also be found round
the margins from which the slough had separated. When a utero-
vaginal fistula is formed it is more usually the result of a laceration than
of a slough. When a recto-vaginal fistula is formed it is generally at the
perineal end of the vagina, and is usually due to a complete perineal
rupture, with partial union by a bridge of tissue between two stitches, the
others having given way. More rarely a slough forms opposite the sacral
prominence, and an opening may be made into Douglas's pouch ; but if so,
the general peritoneal cavity is effectually protected by rapidly effused lymph.

Evidences of Sloughing. — Superficial sloughs along the vagina, and at the
orifice of the vulva, are not uncommon, and are the result of pressure, and of
the " glissading " of the tissues owing to the child's head pushing the tissues
in front of it, detaching the mucous membrane from its deeper attachments,
and depriving it of blood-supply. With antiseptic care these superficial
sloughs are unimportant. If the bladder has been laid open by a slough, it
would be noticed that in from four to ten days urine would be coming
away from the vagina, and the bladder would be found to be more or less
empty. The exact position would probably not be known till some time
after the fistula was diagnosed, for a satisfactory examination could hardly
be made till the parts had involuted.

Prophylaxis. — All such cases of fistula, the result of delayed labour, are
now relatively rare, owing to the forceps being used earlier, and to the
adoption of other measures to prevent undue delay.

Treatment. — This would have to be delayed, and the fistula treated
by a secondary operation after its precise character had been determined.
To surgically treat a fistula, due to pressure, immediately after the separa-
tion of the slough, would certainly prove a failure, owing to the induration
and lack of vitality round the margins of the wound, and the presence of
some cystitis. Time should also be given for the wound to cicatrise, for it
invariably gets smaller, and the operation therefore becomes less severe.
In the meantime, all that can be done is to adopt some suitable palliative
treatment, for, although a radical operation is useless during the puerperium,
much relief can be afforded to the patient, and septic consequences can
usually be averted. The vagina should be douched with some sedative
solution, such as borax (two drachms to the three pints), lysol (dr. 1 to
three pints), or diluted Condy's fluid, and some antiseptic wool or wool-pads
can be kept constantly applied to the vulva, or a suitable urinal can be
worn. Women accustomed to wear diapers at menstruation do not object
to such appliances as much as one would expect. In a few cases patients

Definition ....

. 311

Morbid Anatomy

. 311

Causation ....

. 311

Symptoms and Diagnosis

. 312

LABOUE, INJURIES TO THE GENERATIVE ORGANS 311

do not need to wear anything when recumbent, but all depends upon the
exact position and extent of the fistula.

Six weeks after the labour an operation may be performed. (See
" Vagina.")

C. Acute Inversion of the Uterus

Prognosis . . . . .312
Prophylaxis . . . .312

Treatment . . . . .312

Definition. — This form of uterine displacement is a more or less complete
turning " inside out and upside down " of the body of the uterus, so that its
lining membrane becomes external and its fundus the lowest portion of the
body.

The fundus may be " completely " or only " partially " inverted.

Morbid Anatomy. — When the fundus becomes completely inverted it
draws down with it, into the peritoneally -invested cup, part of the broad
ligaments, with their pampiniform plexus of veins, the round ligaments, the
ovarian ligaments, and sometimes the ovaries themselves, with part of the
Fallopian tube, and more rarely part of the omentum. These so completely
fill up the hollow that the physical examination may fail to feel the cup-like
depression which theoretically exists.

Prolapsus of the uterus or vagina may be also present. In such cases
the fundus, even when the placenta is not attached, may be quite outside
the vulva.

Causation. — This accident is said to occur once in 200,000 labours, and
may be both artificially and spontaneously produced.

Inversion cannot occur if the uterus is„ contracted. The body of the
uterus must be completely relaxed.

(a) Artificial inversion may be caused in two ways : — (1) Forcible expres-
sion during uterine relaxation. — Expression of the placenta during the third
stage of labour should only be practised during a " pain," otherwise indenta-
tion of the fundus may be induced. Partial inversion seems to temporarily
paralyse that portion of the uterus, so that when a " pain " arrives the whole
uterus contracts, except the inverted fundus, which is grasped and driven
downwards in the bine of least resistance, and a complete inversion may
ensue. This may take place during the next pain, or after the lapse of
some hours, or even some days after a partial inversion has been produced.

(2) Traction on the umbilical cord during uterine inertia. The fundus,
with its adherent placenta, may be thus partially inverted, and this may be
converted into a complete inversion either by " expression " or by further
traction on the cord, or spontaneously.

(b) Spontaneous inversion may occur in several ways. As already
stated, a partial inversion may be converted spontaneously into a complete
inversion, but there is no doubt also that an inversion may be induced
spontaneously ab initio. A short umbilical cord, or a cord rendered rela-
tively short by being wrapped round the foetus, may be the primary cause,
and is, according to Herman, the way in which a considerable number of
cases of inversion are brought about. An inert fundus, with a placenta
partly separated, and hanging down into the body of the uterus, may be
inverted exactly as a chronic inversion is produced by a fibroid polypus.
Increase of intra-abdominal pressure, by the patient coughing, sneezing, or

312 LABOUE, INJUEIES TO THE GENEEATIVE OEGANS

" bearing down," encourages inversion to become complete if cupping has been
begun, and, according to some observers, this is thought to be sufficient to
spontaneously produce the initial partial inversion.

Evidence and Diagnosis. — The main symptoms are sudden, severe collapse
and haemorrhage coming on during, or more rarely after, the completion of
the third stage of labour. The collapse is caused by strangulation of the
uterus and its appendages, and is only relieved by reduction of the displace-
ment.

The condition of the patient resembles that due to rupture of the uterus
(see p. 296), but the fact that the uterus cannot be felt over the pubes, and
that the collapse has occurred in the third stage of labour instead of the
second stage, will suffice to differentiate. If the placenta is adherent the
mass will protrude beyond the vulva, and the diagnosis will be obvious.

If the placenta is detached the inverted fundus may, or may not, reach
the vulva, and would have to be distinguished from a fibroid polypus. The
absence of the uterine body from the hypogastrium will sufficiently exclude
the diagnosis of a uterine fibroid, and if the hand be passed into the vagina
behind the swelling, and pressure be made by the other hand, the exact
condition is easily determined.

Prognosis. — The mortality is about 66 per cent. Death may rapidly
ensue from shock or haemorrhage, or may follow in a few days, if the case
be untreated, from hsemorrhage or sepsis, or later on from exhaustion.

If the patient survive and the uterus be unreduced, the inversion
becomes chronic and involution is greatly impeded, and the patient remains
very ill and suffers from much pelvic pain and from continuous haemor-
rhages and discharge.

Prophylaxis. — Forcible extraction of the child or placenta should] be
avoided in all cases of secondary uterine inertia. More particularly should
expression from above, or traction on an adherent placenta from below, be
avoided, except during a definite uterine contraction. If the cord is too
short to permit delivery, it must be cut as soon as the passages are
sufficiently dilated to admit the rapid delivery of the child by forceps.
The relatively short cord wrapped round the child's neck or trunk should
be unrolled or, if need be, divided. G-ood uterine contraction and retrac-
tion of the uterus must be ensured after the birth of the child.

Treatment. — The uterus should be immediately replaced by manual taxis
under anaesthesia. The placenta may be detached if still adherent, and after
the bladder has been emptied the inverted uterus should be grasped by the
right hand, and steady pressure should be made in the direction of the
pelvic veins, while the left hand is steadying the rim of the uterine neck
from above. It sometimes hastens reduction to try and re-invert the parts
of the uterus nearest the rim of the cervix, instead of pushing on the fundus
alone.

Eeduction should be very prompt whilst the uterus remains inert.
Every hour increases the patient's shock and makes reduction more difficult.
A rectal injection of two pints of saline infusion with a little brandy will
rapidly relieve the patient after reduction, but does very little good till that
is effected. Never give ergot till the uterus is reduced.

If the incident be discovered at once, reduction may be effected without
anaesthesia, but if an hour or two have elapsed it will be essential to put
the patient under complete anaesthesia. Manual reduction will usually fail
after some days have elapsed, and reduction will have to be effected by
Aveling's repositor (see " Uterus, Chronic Inversion ").

Antiseptic vaginal douches should both precede and follow reduction.

LACRIMAL APPARATUS, DISEASES OF

313

LITERATURE. — Boulton, Percy, M.D. "The Use of the Purse-string Suture in
Ruptured Perineum," Obst. Soc. Trans, vol. xxxii. p. 380.— Duncan, Matthews, M.D.
Papers on the Female Perineum. — HERMAN, G. E. "Difficult Labour," and "The Morbid
Condition of the Female Generative Organs resulting from Parturition," in System of Gynae-
cology, by Allbutt and Playfair, 1896.— Kelly, Howard. Operative Gynecology, and American
Si/stem of Gynecology and Obstetrics, Injuries and Lacerations of the Perineum and Pelvic
Floor. —Nonius. Text-Book of Obstetrics, 1896. —Phillips, John. Article on "Plastic
Gynecological Operations," in System of Gynecology, by Allbutt and Playfair.— Pinzani.
"Influence of Position on the Form and Dimensions of the Pelvis," Trans. International
Gynecological Congress at Amsterdam, 1899.— Schatz. Archiv fiir Gynec. Bd. xxvii. 1884,
S. 298.— Spencer, Herbekt. Trans. Obstet. Soc. for 1900, "Four Cases of Rupture of the
Uterus successfully treated by packing with Iodoform Gauze."

Lacrimal Apparatus, Diseases of.

Anatomy and Physiology

313

Calculi ... . . 317

Diseases op the Gland .

314

Polypi .... 318

Inflammation

315

Wound, Abscess in . .318

New Growths

316

Diseases op Lacrimal Sac and

Diseases of the Excretory

Nasal Duct .... 318

Apparatus ....

317

Inflammation . . .318

Epiphora ....

317

Stenosis of Duct . . .319

Foreign Bodies

317

The lacrimal apparatus comprises the tear gland, with its excretory ducts,
the puncta, the canaliculi, the tear sac, and the nasal duct. The lacrimal
gland and its ducts constitute the secretory portion, the other structures
named the excretory portion of the lacrimal apparatus, and our subject will
be discussed under these two headings.

Diseases of the lacrimal apparatus are about thrice as common in women
as in men, perhaps in consequence of the more zealous use that the former
make of the function of lacrimation.

Anatomy and Physiology. — The lacrimal gland is a compound tubulo-racemose
gland, resembling the serous salivary glands ; it is about the size and shape of an
almond, measuring rather more from before backwards than from side to side, but
its size varies if one may judge from measurements of accredited observers. It
consists of two portions : the larger, called the superior lacrimal gland, lies in a
depression in the roof of the orbit, just within the upper and outer orbital margin.
This portion is in contact by its upper convex surface with the periosteum of the
orbital roof, to which it is attached by fibrous bands ; the anterior edge corre-
sponds with, but does not project beyond the margin of the orbit ; the posterior
border reaches to the junction of the first and second fourth of the roof of the
orbit ; the lower concave surface is in apposition with the superior and external
recti muscles. The lower portion, also called the palpebral portion or accessory
gland, separated by tendinous strands from the main gland, is less constant in size
and shape, and is sometimes absent ; it consists of one or two small lobules,_ which
lie just beneath the mucous membrane of the superior conjunctival fornix, and
may sometimes be brought into view by eversion of the lid and strong, downward
rotation of the eyeball. The efferent ducts from both portions of the gland, some
eight to twelve in number, open by a row of fine apertures into the conjunctival
sac at the upper and outer part.

The glands of Krause, similar in structure and formation to the lacrimal gland,
are small, rounded bodies, situated chiefly in the upper, but also met with in the
inferior cul-de-sac, and suffice to moisten the eye even if the lacrimal gland is
destroyed. The lacrimal gland in its connection with the conjunctival sac may be
well compared to the salivary glands and the cavity of the mouth. The secretory
nerve of the lacrimal gland is generally reckoned to be the lacrimal branch of the
fifth, but Goldzieher and Jendrassich have recently declared that it belongs to the
facial nerve. According to Kirchstein the gland is very small and rudimentary in
•the new-born child, which accounts for the absence of tears at that period of life.

Under usual conditions the tears are secreted only in sufficient quantity^ to
moisten the conjunctiva and cornea, the greasy edges of the eyelids also preventing

314 LACEIMAL APPAKATUS, DISEASES OF

overflow, the surplus is disposed of by evaporation and by escaping into the nose
through the naso-lacrimal canal. An overflow takes place by direct irritation of
the lacrimal nerve, by reflex irritation of the conjunctiva or nasal mucous mem-
brane, by strong light acting on the retina, or by painful emotion. The tears
escaping from the gland are at once dispersed over the surface of the eye, just like
fluids between a cover-glass and microscopical slide, aided by winking movements
of the eyelids.

The puncta lacrimalia are two pin-point apertures situated near the posterior
edge of the eyelids about 5 to 6 mm. from its nasal commissure. They are not quite
opposite one another, the lower one being about 1 mm. farther from the commissure
than the upper. They lie against the conjunctiva of the bulb, so that they are
visible only when one causes slight eversion of the eyelids. The upper canaliculus
runs vertically upwards from its punctum for a distance of 2 mm., then makes a
sudden bend inwards and downwards ; the lower canaliculus runs vertically down-
wards for a still shorter distance, and then takes a horizontal direction. It is of
practical importance to bear this in mind when probing or slitting the canaliculi.

The canaliculi enter the tear sac separately as a rule, but sometimes by a
common duct ; the openings are situated at the outer side of the sac, but also on
its anterior aspect. The canaliculi are lined by squamous epithelium, differing, as
we shall see, from the lining of the sac and nasal duct.

The lacrimal sac and its continuation, the nasal duct, which opens into the nose
beneath the inferior turbinate bone, in structure, character of secretion, and patho-
logical relations, is to be properly regarded as an accessory part of the nose rather
than of the eye.

Both sac and duct are formed of a fibro-elastic material, with a well-developed
mucous membrane lined by an imperfectly ciliated columnar epithelium. The
lower part of its duct has numerous glands similar to those in the meatus of
the nose. The sac lies in a deep groove formed by the superior maxilla and
ethmoid bone, the bony canal lodging the nasal duct is completed by the inferior
turbinate bone.

The internal palpebral ligament, which can be felt as a hard cord running
inwards from the nasal commissure of the lids, is the best guide to the sac, an
abscess in the latter always points just below this ligament, but the blind, dilated
end of the sac reaches a little distance above it.

The direction of the naso-lacrimal passage is downwards, backwards, and a
little outwards, which it is of importance to recollect when passing a probe. The
diameter of the sac is 5 to 6 mm., that of the nasal duct 3 to 4 mm., and the narrowest
part is usually at the junction of the sac and duct.

An empyema of the frontal sinus may burst into the sac, and an empyema of
the maxillary sinus into the nasal duct.

Diseases of the Gland. — The lacrimal gland possesses almost com-
plete immunity in inflammatory or other affections of the eye ; even in
gonorrhceal and other severe conjunctival inflammations the gland escapes.
The accessory part, however, does occasionally become enlarged in phlyc-
tenular ophthalmia, acute trachoma, panophthalmitis, and some other
conditions, and is recognised as a small, very soft swelling at the upper and
outer part of the superior lid, even when one cannot make it out by touch.

Diseases, and still more injuries of the main mass of the gland are of
rare occurrence, from its protected position and its multiple system of ducts.
Stabs of the upper lid may reach and wound the gland, and if healing is
delayed, and especially if suppuration occurs, a fistulous opening may be
left from which tears escape.

True lacrimal fistula has also been met with as a congenital condition,
and is recognised as an opening in the upper lid so minute as to be easily
overlooked, the tears exuding in very small quantities, and evaporating
almost as soon as they escape. A cure is best effected by passing a needle
armed with a silk suture through the opening in the skin, and bringing it
out in the upper and outer part of the conjunctival sac ; the other end of the
suture hanging from the opening in the skin is then threaded on another
needle, passed through the lid near the fistula, and brought out in the con-
junctival sac near the other. The two ends are tied together and allowed to

LACKIMAL APPAEATUS, DISEASES OF 315

cut their way through. The effect of this is to make the tears find their
way into the conjunctival sac instead of through the opening in the skin,
which now closes of itself, or will do so if the edges be freshened and
brought together by a suture.

Dislocation of the gland is very rare, but has been met with as the
direct result of a blow, from a cicatrising wound of the upper lid, and still
more rarely as a spontaneous condition. The presence in the outer and
upper part of the eyelid of a movable subcutaneous lobulated swelling
about the size of an almond renders the diagnosis easy. Eeplacement is
sometimes possible and should be tried, for it is occasionally followed by cure,
but excision through an incision in the skin is mostly required.

Chalky concretions, called dacryoliths, are sometimes found blocking one
or more of the excretory ducts, and must be removed through the conjunctiva
as they give rise to a good deal of pain.

Inflammation of the lacrimal gland occurs in an acute and in a chronic
form, the former leading to suppuration, the latter to hypertrophy.

The acute form is almost always confined to one side, and is usually
met with in delicate children as the result of a blow or from exposure to
cold.

It is ushered in by a general febrile condition, there is a feeling of
tension, and sometimes very severe pain, shooting to the brow, temple, and
even to the upper jaw. The lymphatic glands of the neck are enlarged,
sometimes to such an extent as to cause cyanosis from pressure on the
jugular vein. There is a painful, tender, dusky red swelling of the outer
part of the upper lid, which hangs down and covers the cornea. The upper
lid is greatly thickened and enlarged, causing obliteration of the natural
folds, the veins are engorged and tortuous, and even some of the arteries
may be seen and felt to pulsate.

The ocular conjunctiva shows all grades of inflammation, even to
most severe serous chemosis protruding from between the lids.

The globe is somewhat protruded and displaced, not directly forwards, but
towards the lower and nasal side, and its movements are always restricted
upwards and outwards, although they may be unimpaired in other direc-
tions. In tenonitis the displacement is straightforward, and the movements
of the globe are restricted in all directions. The gland itself cannot be felt
(compare with the chronic form), on account of the swollen and infiltrated
condition of the lid and tissues underneath, and probably also because the
gland is already in a state of suppuration, and forms no distinct tumour.

Hot fomentations followed by an incision when fluctuation occurs, or
even before we can be certain of this, is the best course ; it is useless to try
abortive treatment in acute cases. It will be noticed that the escape of
pus is followed by 'clear fluid, the tears, which are characteristic of this affec-
tion. The probe sometimes comes upon exposed bone, which has led some
observers to regard these cases, not as suppurative adenitis, but as a localised
inflammation of the bone, a view which I cannot subscribe to. If the
abscess is allowed to burst of itself the pus makes its way through the skin
or into the conjunctival sac, and in the former case a fistula may result, and
require operation as before described.

Chronic adenitis is met with as the result of syphilis, tubercle, leukaemia,
and as an accompaniment of mumps. It may affect both orbits. The first
symptom noticed by the patient is ptosis or drooping of the upper lid,
followed in a day or two by protrusion and displacement of the eyeball with
consequent diplopia. A blunt, often lobulated and elongated swelling is
felt under the outer part of the brow. Sometimes, but not always, there is

316 LACEIMAL APPARATUS, DISEASES OE

dryness of the eye from want of the lacrimal secretion, and this may
exceptionally be so marked that desiccation of the corneal epithelium may
take place. Dryness of the mouth has also been observed from a coincident
affection of the salivary glands, which may or may not be enlarged.

Numbness of the brow on the same side may be present, from pressure
on the frontal branch of the first division of the fifth nerve ; this soon
disappears, but the power of lifting the lid and rotating the eye upwards
persists, the sensory nerve recovering from the effects of the pressure sooner
than the motor nerves, which is in accordance with observations of the kind
elsewhere.

The treatment consists in inunction of mercurial ointment over the
swelling and the brow and temple, with iodide of potassium internally in
syphilitic cases, cod-liver oil with creasote in strumous cases, or arsenic, in
the form of Fowler's solution, when neither syphilis nor tubercle is present.
If the indurated swelling does not disappear we must excise it by an opera-
tion, which will be later described.

Various new growths occur in the gland, and as the symptoms are
similar to those of chronic adenitis we are led to suspect the presence of
some growth if the swelling does not disappear or diminish under treatment,
or still more if it increases in size. It is often impossible before excising
and examining this swelling to say if it is due to simple hypertrophy or
new growth, or whether it is benign or malignant in nature. In children
we meet with sarcoma, in adults with carcinoma, cylindrina, chloroma, also
with gumma, hydatid cyst, enchondroma, and some other rarer varieties of
growth.

Excision of the gland for hypertrophy or new growth is done in the
following manner : — The patient is anaesthetised, the brow is shaved, and the
parts thoroughly cleansed. A curved incision is made down to the peri-
osteum along the outer third of the brow, and if necessary it may be pro-
longed for some distance beyond the external commissure. The edges of
the wound are kept apart by hooks and the tarso-orbital fascia is divided,
exposing the gland, which is drawn forward by a hook and removed in its
capsule if possible. The fascia is united to the periosteum by a catgut
suture, a drain is inserted, and the skin wound closed with silk sutures.

With strict antiseptic precautions the operation is usually free from
risk, but a fatal case has been recorded.

The operation very often leads to permanent cure even when done for
growths, as they are often completely encapsuled, and the changes are con-
fined to the centre of the gland, where cystic spaces often occur.

It is much more often successful than in growths from any other part of
the orbit.

A rare form of cystic growth called dacryops, due to obstruction of one
or more of the efferent ducts of the gland, was first described in 1814 by A.
Schmidt. It appears as a bluish, thin-walled, translucent cyst with fluid
contents, which springs into view beneath the upper lid. In some of the
cases, from imperfect closure of duct, its contents, which become much more
tense on crying, may escape gradually or be from time to time pressed out
by the patient. A well-recorded case has been described by Arnold Lawson
in vol. xvii. Trans. Ojohth. Socy., and an interesting paper by Hulke in vol. i.
Royal London Oplith. Hosp. Reports should be read. An attempt should
be made to excise the cyst entire, as was successfully done in Lawson's
case, but even if only a large piece of the wall is removed a cure is often
effected.

LACRIMAL APPAKATUS, DISEASES OF 317

Diseases of the Excretory Apparatus

Diseases under this heading are much more common than diseases of
the lacrimal gland, and are hence of more practical importance. They are
met with more often in adults than in children, but some are congenital in
origin. Heredity from the mother's side plays an important part in their
causation.

Puncta and Canaliculi. — A constant symptom in all diseases of the
excretory apparatus is epiphora or overflow of tears down the cheek, and
when the puncta and canaliculi are the parts involved this may be the only
symptom. Epiphora is always aggravated by cold wind, dust, or smoke, and
necessitates the constant use of the pocket-handkerchief. Although weeping
is always present in diseases of the lacrimal passages, its presence does not
always prove the existence of anything amiss with those parts, for it may
be caused by inflammation of the conjunctiva, cornea, or iris, and some
people, quite free from ophthalmic disease, are liable to a temporary epiphora
on coming into the fresh air. It is frequently associated with morbid blush-
ing, and also occurs in the early stage of Graves' disease. Practically,
however, in all cases coming under treatment it is the drainage apparatus
that is at fault. Epiphora is by no means always due to stricture of the
canaliculi, the slightest displacement of the puncta, particularly the lower,
which is functionally the more important, will produce it, and hence we
have it in ectropion of the eyelids, especially of the lower, also in entropion,
where the inturned lashes also set up irritation and excessive secretion of
tears. Epiphora may also be due to the presence of a Meibomian cyst or
other tumour of the inner part of the lower lid, and is seen in old people
from relaxation of the lid and in paralysis of the facial nerve — conditions all
inimical to the proper approximation of eyelid and globe.

In old-standing neglected blepharitis the edge of the lid becomes rounded
and slightly everted, the secretion of the Meibomian glands is diminished,
and the tears readily overflow. The tears, containing as they do a large
proportion of salt, set up irritation and inflammation of the skin, accentuat-
ing the ectropion and giving rise to constant blepharospasm and dis-
comfort.

The treatment consists in slitting up the lower canaliculus by means of
a Weber's probe-pointed knife, thus converting the little tunnel into an
open rill, which must be prevented from closing by passing a probe along it
for some days after the operation. This operation will be mentioned more
fully later on.

The same procedure is to be adopted when the epiphora is due, not to
displacement, but to stenosis or abnormal narrowing of the canaliculi or
puncta.

In these cases the puncta become so minute as to require the aid of a
magnifying lens to make them out ; and we must first dilate the passage by
a conical sound so as to admit the beak of the Weber's knife.

Small foreign bodies, such as an eye-lash, the wing of an insect, a wheat
bristle, etc., may be carried by the flow of tears from the conjunctival sac
into the canaliculi, almost always the lower, and protruding from the
punctum, will rub against the eye and give rise to some pain, irritation, and
overflow of tears. The treatment consists in the removal of the foreign
body by means of forceps.

Calculi composed of carbonate of lime and leptothrix threads sometimes
block the canaliculus, a condition recognised by the presence of a little
fusiform swelling, and requiring slitting up of the passage for its removal.

318 LACEIMAL APPARATUS, DISEASES OF

Polypi in this position are still rarer, and if luxuriant may protrude from
the punctum.

In cases of wound of the lower lid dividing the canaliculus, the permea-
bility of the passage must be ensured by slitting up both distal and proxi-
mal parts before suturing the edges of the wound. Congenital absence of
one or both puncta is occasionally met with, but is not usually associated
with epiphora, probably on account of a compensatory imperfection or
absence of the lacrimal gland. An accessory punctum and canaliculus may
very rarely occur, mostly in the lower lid. It may end blindly or open into
the tear sac, or it may open into the canaliculus, in which case it may be
regarded as a congenital fistula of that passage.

Diseases of the Lacrimal Sac and Nasal Duct

The mucous membrane of the sac is subject, like the conjunctiva, to
catarrhal and purulent inflammation, the starting-point being almost always
in the nose and not in the conjunctiva. It is astonishing but no less true
that purulent conjunctivitis practically never extends to the lacrimal sac ;
perhaps the thick layer of pavement epithelium lining the canaliculi to some
extent accounts for this. In trachoma, however, the lining membrane of
the sac has in some instances been found affected with a like disease, the
two regions being probably simultaneously attacked. In thirty-eight cases
of disease of the sac, G-ruhn, in all but two, found nasal disease as simple
chronic coryza, atrophic or hypertrophic rhinitis with or without ozsena, etc.,
with obvious signs of the nasal disease being of much older standing than
that of the tear sac. Michel thinks that the lacrimation which snuffers of
tobacco suffer from or (?) enjoy, is due not only to reflex stimulation of the
lacrimal gland, but also to the chronic inflammation of the nasal mucous mem-
brane extending up the nasal duct and narrowing it. There is no doubt what-
ever that if one takes the trouble to make inquiries in cases of lacrimal
trouble, one will get a history of repeated colds in the head, if not direct
evidence of intra-nasal disease.

Malformation of the nose, in the form of flat-nose and deviation of the
septum, is a predisposing cause in many cases.

The secretion in the sac, especially if purulent, contains the staphylo-
coccus pyogenes aureus and albus and streptococcus pyogenes. The
bacilli of tubercle may also be present, and should be looked for as an aid
to diagnosis.

Vegetations in the nasal fossa may block the end of the duct, as may
also syphilitic or tubercular ulcers. Lupus of the nasal cavity is a very
common cause of stoppage of the canal.

Catarrh of the sac comes on very insidiously, and at first gives rise only
to epiphora most marked in the morning or in cold wind.

This symptom soon becomes constant, and is associated with ciliary
blepharitis, redness, swelling, and discharge from the caruncle and adjacent
conjunctiva, a condition called conjunctivitis angularis or lacrimalis,
which should always lead us to suspect infiammation in the sac, especially
if only in one eye.

The diagnosis is made certain by gently opening the lids with the
fingers of one hand, while pressure is made on the sac with the tip of a
finger of the other hand. Catarrh of the sac is made known by the escape
from one or both puncta of a few drops or a tiny stream of turbid fluid.

In time the sac becomes distended, forming a characteristic rounded
swelling at the corner of the eye, and the patient very soon learns the trick

LACEIMAL APPAEATUS, DISEASES OF 319

of emptying this by pressure. In some cases pressure empties the contents,
not into the conjunctival sac, but into the nose.

This condition of slight distension of the sac may remain unchanged
for an indefinite time if the patient regularly empties it and keeps the eye
clean, but from a fresh coryza stagnation and decomposition of the contents
takes place, giving rise to 'purulent cystitis.

Here the symptoms are for the most part similar to, but more intense
than in the catarrhal form. The eyelids in the morning are glued together
by profuse muco-purulent secretion, the lashes are covered by crusts, the
conjunctiva is swollen, red, and even chemotic. The expressed contents
of the sac are markedly purulent, and there is a painful feeling of
distension in the region of the sac.

A third stage called phlegmonous dacryocystitis may supervene from
extension of the inflammation to the parts outside the sac. The onset is
rapid, and accompanied by general febrile symptoms and intense pain,
the patient in some cases becoming almost maniacal.

The neighbouring soft parts are infiltrated so that the limitations of
the sac can no longer be made out, but are merged in the general swelling,
which is hard, brawny, and shining.

The puncta are with difficulty brought into view, and the ocular
conjunctiva is chemotic. The condition might be mistaken for erysipelas,
but the extreme tenderness just over the sac and the history of a preceding
lacrimal discharge ought to prevent such a mistake.

The pain is so excessive that, as a rule, we are not enabled to help our
diagnosis by pressing out pus from the puncta as in the catarrhal stage.

The abscess points just below the tendo-oculi in most cases, but it
sometimes burrows under the orbicular muscle, and escapes at some distance
below the lower eyelid. The symptoms rapidly abate on the escape of
•the pus, and the swelling subsides so that the limits of the distended sac
are again made out. A fistulous opening is very apt to be left. In some
few cases the pus escapes from the puncta, and it has been known to make
its escape by perforation of the lacrimal bone, but this is exceedingly rare.

The swelling and infiltration of the mucous membrane is alone sufficient
to cause retention of tears and pus, and actual stricture is by no means
usually present — in fact it is distinctly exceptional, and when present is
to be regarded, as in stricture of the urethra, not as the cause, but as the
effect of the inflammation in the canal. Stenosis can be diagnosed only
after surgical treatment by probing, and we will have more to say on this
subject under the heading of treatment.

Disease of the bone forming the walls of the canal is often met with
in syphilitic and tubercular cases ; it is probably always the cause and not
the effect of the purulent cystitis, but rough treatment in probing may
give rise to it.

In some cases of long-standing obstruction the sac becomes greatly
distended, forming a tumour almost the size of the first joint of the thumb.
The over-lying skin is much attenuated, semi-translucent, and bluish, and
the condition might be mistaken for a varix. The swelling is incom-
pressible, and it is usually not possible to empty it either into the nose or
into the conjunctival sac. This condition is called a mucocele or hydrops,
and is due to distension of the sac with glairy fluid.

Dermoid tumours, although of course almost always situated at the
outer part of the brow, do sometimes occur in the region of the sac, and
might then be mistaken for mucocele, as has occurred more than once in
my own experience.

320 LACRIMAL APPARATUS, DISEASES OF

A mucocele of the frontal sinus, with or without infiltration of the
anterior ethmoidal cells, might be confounded with a hydrops of the sac,
but the former condition soon gives rise to proptosis and lateral displace-
ment of the eye with consequent diplopia, which is never the case with
dilatation of the sac, however great.

Of late years a good deal has been written concerning the so-called
congenital blennorrhea of the sac, which is really due to retention of the
normal mucus from a membranous obstruction at the lower end of the nasal
duct, a condition which Vlacovich found four times in the examination of
fourteen bodies of new-born infants. This affection is nearly always con-
fined to one eye, and the characteristic symptom noticed by the parents a
day or two after birth is the presence within the lower eyelid of a quantity
of glairy mucus. If the secretion be gently wiped away and pressure then
made on the sac, the source of the discharge can be proved by the escape of
some from the puncta. It is only seldom that any distension of the sac
can be made out. The secretion may rarely in older standing cases be-
come slightly purulent. I have known the condition to be mistaken for
ophthalmia neonatorum by those not overburdened with ophthalmic
knowledge.

It has been noted by Heddaus, and confirmed by others, that the
secretion, like all physiological secretions, is in abeyance during sleep, so
that if the eye be cleansed last thing at night, it will be free from the
mucus for some hours after the child awakes in the morning.

These cases, unlike real dacryocystitis in later life, show a tendency
to become cured rapidly and spontaneously from giving way of the
membranous obstruction. It is therefore advisable at first to content
ourselves with keeping the eye clean by frequent use of a soft rag, and
making pressure over the region of the sac. If a cure is not soon effected
by these means the case must be treated as an ordinary dacryocysto-
blennorrhcea.

Treatment. — The best and most rapid cures are obtained in cases which
are not accompanied by strictures, disease of the bone, or great distension
of the sac, but even in the presence of these complications good results
may be obtained by patience.

As soon as the diagnosis is established by the mucous or muco-purulent
discharge from the puncta we may make up our mind that an operation
is required. Delay can do no good. Purulent or even phlegmonous
inflammation may supervene at any time, and any slight abrasion or ulcer
of the cornea may give rise to hypopyon keratitis and loss of the eye.
If any surgical operation on the eye, especially cataract extraction, be con-
templated, it is of course absolutely necessary to cure any lacrimal trouble
first, or we should be practically certain to lose the eye from suppuration, —
an unfortunate result not infrequently due to overlooking a slight discharge
from the sac.

We have to do with a catarrhal or purulent process taking place in what
is practically a closed sac, and our aim is to get free access to the cavity,
empty its contents, prevent their reaccumulation, and bring the mucous
lining into a healthy condition. Entrance into the sac used to be gained
by an incision in its anterior wall, but since Bowman's time this is done by
his method of splitting the canaliculus and freely incising all the tissues
at the neck of the sac. This operation is the only great advance that has
been made in the treatment of lacrimal disease since quite ancient times.
The patient is laid on his back, and a few drops of a 4 per cent solution of
cocaine having been repeatedly instilled into the corner of his eye, the skin

LACRIMAL APPARATUS, DISEASES OF 321

of the lower lid is kept on the stretch by means of outward traction with
the thumb of the left hand, and (the right eye is here supposed to be under
operation) the surgeon standing behind the patient's head inserts the beak
of the Weber's knife vertically into the lower punctum, turns the cutting
edge upwards and a little backwards, and, keeping the handle almost parallel
to the lid margin, thrusts it slowly and steadily inwards till the probe
point impinges on the lacrimal bone. By raising the handle like a lever,
while still keeping the point against the lacrimal bone, the canaliculus may
be slit along its entire length. The knife should now be felt to lie quite
freely and movable in the sac, but if this is not the case slight sawing
movements will bring it about. In operating on the left eye the surgeon,
standing as before, keeps the lid on the stretch with the thumb of his right
hand, and uses the knife with his left, or if he finds it easier, he may stand
on the patient's left side, facing him, and so get the advantage of using the
knife with his right hand. Some prefer to have the patient seated on a
chair with the head, covered by a towel, resting on the chest of the operator
who stands behind.

The surgeon now passes a probe about 2-3 mm. in diameter along the
divided canaliculus till it is arrested by the lacrimal bone, and raising it to
a vertical position against the brow, thrusts it steadily downwards, backwards,
and a little outwards till it is arrested on the floor of the nose. To do this
satisfactorily requires some confidence, which comes by practice. If the
upper end of the probe, after being pushed down, stands forwards away
from the brow, we have probably made a false passage, which is more likely
to take place in using the smaller probes, hence it is a good rule to use as
large a probe as will easily pass. I have known the probe to make its
appearance in rather unexpected places, for instance, in the cavity of the
mouth behind the soft palate, and on another occasion, from too vigorous
use, it has gone through the roof of the mouth. Some skilled surgeons pass
the knife itself down into the nose, which certainly ensures an easy passage
for the largest probe, but this had better not be done by those of little ex-
perience, as with such a fragile instrument the blade is apt to break off and
be left in the nasal duct, and false passages are more easily made than by
the probe. A more than usually prominent brow renders the use of a
straight probe difficult or impossible, and generally the curved probes of
Couper are the best to use.

It will generally be found that 1| to If inches of the probe are concealed
when thrust home. Its lower end may often be felt by means of a second probe
passed along the floor of the nose for a distance of 1^ inch from the pos-
terior edge of the nostril. This cannot be done in every case, as the opening
of the duct is often on the outer wall, and not in the roof of the inferior
nasal fossa, and is then protected by a flap-like arrangement of the mucous
membrane.

The probe is passed twice a week till the discharge ceases, or at least
loses its purulent appearance, but we must be prepared for relapses in many
cases.

Strictures are diagnosed and localised best by the olive-pointed probes
of Couper, and occur most frequently at the junction of the sac and nasal
duct, but also at the nasal end of the duct and also at the neck of the sac.

Great patience both on the part of the patient and the surgeons is
called for. If a small probe can be passed we may hope for amelioration
by the use of gradual dilatation, but if the stricture is osseous in nature it
is probably incurable. The use of a dental drill has been recommended in
such cases.

VOL. vi 21

322 LACEIMAL APPAEATUS, DISEASES OF

In phlegmon of the sac we must first make a deep vertical incision over
the sac, and after escape of the pus lightly pack the cavity with iodoform
gauze, which is renewed each day till the swelling of the tissues has been
dispersed, when Bowman's operation is then done. The opening in the
skin will gradually close if probes are passed by the slit canaliculus. In
disease of the bone the pus forms burrows in various directions, and these
must be freely laid open from end to end and well scraped with a sharp
spoon. Injection of iodoform emulsion into the sac may also be done.
In strumous and syphilitic cases the appropriate constitutional treatment
must not be neglected.

In very obstinate cases, where, in spite of probing, the discharge remains
purulent and very profuse, injections by means of a hollow perforated probe
and syphon arrangement is good practice. For this purpose we may use
0'6 per cent sulphate of zinc, 1 per cent acetate of lead, 0*02 per cent
corrosive sublimate, 2 to 5 per cent nitrate of silver, or best of all 10
per cent protargol. If this does not suffice to dry up the discharge,
Fick recommends the injection into the sac of a few drops of a 10 per
cent solution of chloride of zinc, first protecting the cornea by a thick
layer of vaselin. Severe reaction takes place, but a good result is obtairied.

In cases of chronic distension of the sac, and in cases of incurable
stricture, the best thing to do is probably to destroy the sac. This opera-
tion, I am informed by my colleague Dr. Little, used to be frequently done
by Mr. T. Windsor and himself with good and permanent results, and why we
should have discarded it during the last twenty-five years he cannot say.
An incision was made commencing below the tendo-oculi at about 4 mm.
from the inner commissure. To lay open the whole length of the sac, as is
necessary, we prolong the incision upwards to include the fundus. The
bleeding was stopped and the cavity stuffed daily for a few days, when a
strong paste containing 20 per cent zinc chloride was introduced on strips
of lint, the final result being a firm by no means unsightly scar. Excision
of the sac is a very difficult operation, and is more often commenced than
completed, resolving itself into a rather haphazard cutting and scraping
away of the tissues.

LITERATURE. — Monographs: In addition to the text-books were consulted: — Bock,,
Emil. Zur Kenntniss der gesunden und kranken Thranendriise. Vienna, 1896. — Stengel,
Andreas. Ueber das Sarcom der Thranendriise. Munich, 1866. — Fttchs, Ernst. "Gleich-
zeitige Erkrankung der Thranendriisen und der Parotiden," Beitrage zur Augenheilkunde,
1891. — Ltjdowig, Fritz. Zur Frage der Thranendriisentumoren. Rostok, 1883. — Prohl,
Friedrich. Zur Casuistik der Geschioilltze der Thranendriise. Berlin, 1892. Good resume' of
all cases to date : — Homp, Georg. Bin Fall von Angio • Myxosarkom der Thranendriise.
Konigsberg, 1896.— Doring, Gustav. Bin Fall von acuter Dakryoadenitis. Greifswald, 1897.
— Susskind, Jacob. Tuberkulose der Thranendriise. "Wiesbaden, 1897. — Baas, K. L. "Ueber
einige seltenere Erkrankungen des Thranen-Apparates," Miinich. med. Woch. 1894, No. 6.
— Vossitjs, A. " Ein Beitrag zu den kongenitalen Affecktionen der Thranenwege, " Beitrage
zur Augenh. ii. — Grtjhn, Heinrich. Ueber Dacryocysto-blennorrhoe bei Erkrankungen der
Nase. Inaug. Dissert. Munich, 1888.

Lactation. See Puerperium ; Infant - Feeding ; Mammary
Gland.

Landry's Paralysis. See Paralysis.
Laparotomy. See Intestines, Uterus, etc.

LAKDACEOUS DEGENEEATION 323

Lardaceous Degeneration.

Definition .

. 323

Clinical Characters

. 325

General Characters .

. 323

Diagnosis .

. 327

^Etiology .

. 323

Prognosis .

. 328

Chemistry .
Pathology .

. 324
. 324

Treatment

. 328

Syn. : Amyloid, Waxy, or Albuminoid degeneration.

Definition. — Amyloid degeneration is a peculiar change, affecting certain
organs, by which the whole or certain parts of them are converted into a
structureless homogeneous substance called amyloid or lardacein.

The organs most frequently affected are the liver, spleen, kidneys, and
intestines; but lymphatic glands, the stomach and alimentary canal, the
bladder, prostate, generative organs, serous membranes and muscles may at
times undergo this change. The same substance also occurs locally in
tumours, thrombi, and scars, especially those resulting from syphilis.

General Chaeactees. — Organs affected with amyloid degeneration are
generally pale in colour, firm in consistency, and much enlarged : the capsule
appears stretched and tense, and the edges are somewhat rounded, though
the general shape of the organ is maintained. On section, the cut surface
presents a peculiar smooth glistening appearance, owing to which the name
" lardaceous " was applied to this condition. The organ is bloodless in conse-
quence of the pressure exercised by the newly-formed material upon the
blood-vessels of the part, and the diminution in their calibre produced by
the amyloid change in their walls ; and to the same cause is due the fatty
change in the active cells of the organs, which generally accompanies advanced
stages of the process. Microscopically, in the early stages, the affection* is
frequently limited to the subendothelial layer of the intima and to the middle
coat of the smaller blood-vessels, the arterioles and capillaries being affected
before the veins: later it spreads to the connective tissue of the organ. Owing
to pressure and diminished blood-supply, the essential cells of the organ may
be found to have largely disappeared by fatty degeneration and absorption.

Amyloid substance may be recognised, when invisible to the naked eye,
by its peculiar staining reactions. If on the freshly-cut, washed surface there
is poured a solution of iodine, the amyloid substance at once takes on a rich
brown (mahogany) colour, while the unaffected tissue is only stained a faint
yellow. The same staining may be used for microscopic sections, but fades
rapidly, and is therefore useless for permanent preparations. Further, if
to sections thus coloured there be added a 10 per cent solution of sulphuric
acid, a peculiar greenish colour is produced in the diseased portions. The
best stain for microscopic purposes is afforded by methyl or gentian violet.
In sections stained with these dyes and subsequently treated for a few
minutes with weak acetic acid, the amyloid substance is stained a bright
magenta colour, the surrounding tissue appearing blue. These colour-
reactions are not absolutely constant — that with iodine and sulphuric acid
being apparently seen only in very advanced amyloid degeneration, and the
simple iodine-staining sometimes failing to appear in tissues which have
been long preserved. The violet reaction is the most constant and reliable.

-^Etiology. — Amyloid disease is stated to occur more frequently in males
than females, and originates almost invariably in persons below the age of
thirty. It occasionally seems to occur as a primary disease, but many of
such cases are probably due to causes of which all trace has disappeared.

In the great majority of instances it is induced by long-continued

324 LAEDACEOUS DEGENERATION

suppuration, such as that existing in connection with chronic bone-disease,
or tuberculosis of lungs, joints, or kidneys. It is also found in tertiary
syphilis, and rarely in the cachexia of malignant disease or malaria. It can
be produced experimentally in animals by inducing and maintaining
suppuration by means of cultures of the Staphylococcus pyogenes aureus.
Some observers have stated that the same result follows on suppuration
produced by the Bacillus pyocyaneus, or even by turpentine, but these
results have not been confirmed.

Chemical Nature. — Amyloid substance presents a marked resistance
to the action of the gastric juice ; by the action of this ferment it may
be obtained practically pure. It has been shown by Krawkow to consist
of an organic acid (chondroitin-sulphuric acid) combined with some form of
albumen. This latter portion of the compound is probably not constant in
composition, and it is possible thus to account for the varying behaviour of
different specimens in respect of staining. Amyloid substance is very
closely allied to " hyaline," which is considered by some authorities to be
either identical with it, or, at least, its forerunner. A substance giving the
same reactions as amyloid is found in the coats of the aorta and arteries
under normal conditions, so that the pathological product appears to have a
physiological prototype.

Pathology. — Since amyloid degeneration secondary to suppuration is
limited almost entirely to cases presenting ill-drained cavities and sinuses,
it seems probable that it is the result of the absorption of some poisonous
product formed by the bacteria to which the suppuration is due. This
theory is confirmed by the results of the experiments on animals quoted
above. Possibly the toxine injuriously affects the metabolism of the cells
— the digestion by the cells of the circulating albumens of the lymphs — and
thus are formed unusual derivations of albumen, which are deposited in or
around the cells. Authorities appear to incline towards calling amyloid
change an " infiltration " rather than a " degeneration " proper, but it is
doubtful whether any rigid distinction between these two processes is main-
tainable. Some recent observers have endeavoured to trace a connection
between amyloid substance and haemoglobin. Thus Petrone attributes the
degeneration to soaking of the tissues with dissolved blood-pigment, many
corpuscles being broken up in the course of wasting diseases such as syphilis,
tuberculosis, or chronic suppuration ; while Obrzut considers that the masses
of amyloid occurring in the spleen are composed of conglomerated hsemocytes
which have undergone a peculiar transformation. It seems difficult, on
either of these hypotheses, to account for the great swelling of the affected
organs and the amount of pressure apparently exercised by the new product
upon the surrounding cells.

Morbid Anatomy

Amyloid Liver. — The liver is much enlarged and may fill the greater part of
the abdominal cavity. It is pale in colour, and the surface is smooth and regular,
the normal shape of the organ being preserved. The specific gravity of the tissue
is increased, and it is firm and resistant in consistency. On section, little blood is
found in the organ ; the cut surface is smooth and glistening, of a grayish red or
dirty yellow colour. In early stages the outlines of the individual lobules may be
distinguishable, but later on all trace of structure is lost. If a portion is stained
with iodine a very characteristic appearance is produced, each lobule being -marked
out as a thick, dark brown ring, with a pale centi'e, separated by pale substance
from neighbouring rings. This appearance is due to the fact that the amyloid change
occurs principally in the middle zone of each lobule, in the area of distribution of the
hepatic artery. The periphery of the lobule is the seat of fatty degeneration.

Amyloid Spleen. — Two varieties of the degeneration in this organ are dis-

LA11DACE0US DEGENERATION 325

tinguished :— (1) The change may be limited to the Malpighian corpuscles, which
present the appearance of grains of boiled sago set in the substance of the organ,
from which the condition is known as sago spleen. (2) The connective tissue
forming the trabecular may be affected throughout, the cells also appearing to
undergo degeneration, while the Malpighian corpuscles escape. This is known as
the diffuse form. A mixed form is also described, in which both of the above
changes occur simultaneously. The organ is enlarged, pale, firm, and heavy, the
greatest enlargement occurring in the diffuse and mixed varieties.

Alimentaey Canal. — Here the change appears late, and never occurs without
the simultaneous affection of other organs. The intestine is little altered in
appearance to the naked eye, but may look unduly pale and translucent, and feel
thickened and rigid. On pouring a solution of iodine on to the mucous surface, the
whole appears stippled with closely-set brown dots, which correspond to the villi,
the central arteries of which are the main seat of the change. Owing to increased
rigidity thus produced the villi are liable to be broken off, and ulcers may be
formed. Very intractable diarrhoea results from this degeneration, owing probably
to exudation of increased quantity of serous fluid through the degenerated vessels.
Absorption may also be interfered with, and nutrition correspondingly impaired.
If the stomach is the seat of amyloid disease, obstinate vomiting may be the
result.

Amyloid Kidney. — The appearance of the kidney when subject to amyloid
change varies with the extent of the lesion and with the amount of the inflam-
matory process which often accompanies it. In the earliest stage the kidney may
look practically normal, and only reveal on treatment with iodine a few scattered
brown points or streaks showing the existence of the disease. Later on the organ
becomes large, the cortex being pale and anaemic, the pyramids somewhat dark in
colour. The capsule still strips easily, and the cut surface is smooth and glistening.
On addition of iodine the Malpighian bodies show up as brown dots in the swollen
cortex, and the arteries are mapped out as brown lines. Small yellowish streaks
of fatty degeneration are usually present. Still later, in cases complicated by
much nephritis, there may be shrinking of the newly -formed fibrous tissue :
cysts may be found in the cortex of the organ and the capsule may become adherent.
The naked-eye appearances resemble very closely the ordinary large and small white
kidneys of chronic tubal nephritis. Microscopically, it is found that the change
starts in the glomeruli and spreads to the middle coat of the afferent arteries and
arterise rectse, finally involving also the connective tissue throughout the organ.
The epithelium of the tubes does not undergo amyloid change, but is frequently
found in a condition of cloudy swelling and degeneration, owing to accompanying
nephritis. In chronic cases interstitial inflammation may cause increased for-
mation'of fibrous tissue, and the :tubules may become blocked and give rise to
small cysts. The exact relation of the nephritis to the amyloid disease is not
known, but it seems probable that the existence of the degeneration and the
pressure exerted by the new material diminish the resistance of the essential cells
of the kidney, and predispose them to attack by irritant substances, one of which
may even be the same toxin which gives rise to amyloid degeneration. It is note-
worthy that when amyloid disease of the kidneys is secondary to suppuration
occurring in one of these organs, both are equally affected by the degenerative
process.

Effects. — It is impossible to separate the effects produced by amyloid
disease of the liver and spleen from those of the primary cause of the
degeneration. In the case of the kidney and intestine, however, definite
symptoms are produced, disease of the former leading to albuminuria
and even dropsy and uraemia (see below), that of the latter to a severe and
intractable form of diarrhoea, which invariably terminates fatally.

Clinical characters. — Patients suffering from lardaceous disease due to
syphilis or occurring as a " primary " condition may not, at first, present
any very marked degree of wasting; but in cases due to suppuration
emaciation is profound, and all the symptoms of hectic fever are usually
present. There is marked anaemia in all cases. The abdomen is enlarged
owing to the increase in size of the liver and spleen, and occasionally to
accompanying ascites ; but, apart from cases with general dropsy, coexisting
cirrhosis, or perihepatitis, it is probable that this symptom only occurs when

326 LARDACEOUS DEGENERATION

there are enlarged glands pressing on the portal vein, or in the rare instances
in which the radicles of this vein are affected by the degeneration. The
organs are generally painless and not tender to the touch, but in some cases
both pain and tenderness may be found. The edges of both liver and spleen
may be easily felt through the thin abdominal wall, smooth, firm, and
regular, reaching often below the umbilicus, and sometimes separated by no
very clear dividing line. The urine is increased in quantity and contains
albumen in varying but always considerable amounts ; and diarrhoea, due
to implication of the intestine, appears towards the end. Experience of cases
that have occurred in Charing Cross Hospital shows that the liver is the
organ usually first recognised as affected, and that it may attain a large size
before the spleen is palpable. The kidney suffers next to the spleen, and
the intestine only in very advanced stages. In some cases, however, especi-
ally those due to syphilis or to primary renal tuberculosis, the kidney may
be, from the outset, most markedly affected, amyloid change in the other
organs being only detected after death.

The course of the disease is almost invariably progressive, owing to the
difficulty of treating the primary cause. Cases, however, in which the
suppuration can be stopped, may recover from the amyloid degeneration ;
and this has been shown to occur also in animals. Amyloid disease is a
comparatively rare affection at the present day, owing to the introduction of
antiseptic methods in surgery, and the consequent diminution in the
number of cases of suppuration. Children suffering from hip-disease are
probably its most frequent victims, but, apart from suppuration, it is a rare
affection at this period of life.

The clinical symptoms of amyloid kidney must be considered in detail,
since the degeneration may affect this organ primarily, and give rise to
phenomena liable to be attributed to ordinary nephritis. In cases due to
continued suppuration the liver and spleen generally suffer first. After a
time the urine begins to increase in quantity and becomes pale in colour, the
density being correspondingly diminished ; later on it becomes albuminous,
the percentage of albumen at first being small. As a rule the disease of the
kidney is not, in such cases, of any vital importance. In syphilitic cases, on
the other hand, or in such as are apparently primary, it is often only in
advanced stages that the sufferers come for treatment. In addition to the
pallor and malnutrition of the patient, the urine is found loaded with albu-
men, pale in colour, and often neutral or alkaline in reaction. The quantity,
at this stage, may be normal or even diminished, but is more often increased
to seventy or eighty ounces, rising in some cases to as many as 200 oz. per
diem. Hyaline and granular casts are found and may stain brown with
iodine. Ziegler denies that they are really amyloid. The salts of the urine
are diminished in amount, the percentage of urea falling along with the rest,
but not as a rule to a dangerous extent. This feature is probably due to
accompanying nephritis and not directly to the degenerative change. The
amount of albumen is very variable, and the cause of its presence has been
differently explained. Thus some maintain that it is proportionate to the
extent of the amyloid change : others (Lecorche) affirm that its presence is a
proof of nephritis. In some few cases it may be entirely absent (Litten).
Paraglobulin is often present in large amount, and may exceed the quantity
of serum-albumen. Intercurrent attacks of nephritis occur in which hsema-
turia may be prominent, and the urine scanty, dark, and of high density ; it
may even be actually suppressed. Dropsy may be well marked, and ursemic
convulsions or coma may supervene in rare instances. No alteration in the
vascular tension usually occurs in cases of amyloid kidney, and the heart is

LAEDACEOUS DEGENEEATION 327

of normal or reduced size. Failure of the heart may occur, leading to
diminished urinary flow, and in advanced cases to actual death.

Diagnosis. — In patients suffering from chronic suppuration no diffi-
culty is found in recognising the onset of amyloid disease. The gradual
enlargement of liver and spleen, the increasing albuminuria and polyuria,
and the final onset of uncontrollable diarrhoea, present a striking clinical
picture. On the other hand, in cases where the suppuration has ceased, and
in those due to syphilis or some undiscovered cause, considerable doubt may
exist. If a patient presents a uniform enlargement of both liver and spleen,
there may arise, in adults, suspicion of cirrhosis of the liver or of leuchsemia ;
in children, of congenital syphilis, or of mediastinitis with adherent peri-
cardium and strangulation of the inferior vena cava. In alcoholic cirrhosis
the history of the case may be an aid to diagnosis, and the appearance of
the patient is seldom suggestive of lardaceous disease, the tendency being to
venous stigmata and congestion of the face rather than pallor. Diarrhoea
may occur in either condition, but is more intermittent in cirrhosis, and
ascites is far more likely to occur in the latter disease. This last symptom
is also prominent in adherent pericardium, in which, however, pleural
thickening or effusion is frequently present, while the area of cardiac dulness
is markedly increased. Leuchsemia will be excluded by an examination of
the blood, though the increase of leucocytes may be temporarily absent. It
must be remembered that some degree of leucocytosis may occur in suppu-
rative cases, but here the leucocytes will be found all to belong to the multi-
nucleated variety, no increase occurring in the lymphocytes or in the large
uninucleated cells. Syphilitic enlargement of liver and spleen in children
may be indistinguishable from amyloid disease, but the latter does not often
occur at this age as a manifestation of syphilis. A history may be obtained
of some suppurating lesion if such has existed, and will point to probable
amyloid degeneration. If only the liver or the spleen is enlarged, diagnosis
may be very difficult or even impossible. The history of the case will be
the greatest aid, and the possibility of amyloid change must be constantly
borne in mind. The existence of scars, pointing to past syphilitic lesions,
or to old sinuses and disease of bone, is often of importance. Signs of con-
genital syphilis may be found in keratitis, in scars at the corners of the
mouth, in malformation of the teeth, and in deafness due to bilateral otitis
media. A case is recorded (Affleck) in which a misshapen amyloid left lobe
of the liver exactly resembled a splenic tumour, and no certain diagnosis
was possible during life between amyloid disease and splenic anasmia. In
this case there was no history of syphilis nor of any other recognised cause
of amyloid degeneration. In cases commencing in the kidney, diagnosis
from ordinary tubal nephritis is often difficult — indeed the two conditions
may actually be coexistent. Signs of amyloid disease elsewhere may be
found, in slight enlargement of the liver and spleen, which might escape
notice if not carefully sought. Any signs of syphilis will be very sug-
gestive of degeneration. Past residence in the tropics is also to be looked
upon with suspicion, as malaria and dysentery are possible factors in the
production of amyloid. The condition of the heart and arteries is an
important diagnostic feature, since in nephritis sufficiently advanced to
cause the amount of albuminuria met with in amyloid disease the pulse
will almost certainly be of high tension, and the left ventricle of the
heart enlarged so as to cause the apex-beat to be displaced. In uncompli-
cated amyloid disease neither of these features is found. Heart-failure in
renal disease may, however, somewhat mask the extent of the vascular
change, while on the other hand it must be borne in mind that in children

328 LAKDACEOUS DEGENEKATION

under six years of age the apex-beat may be normally near the nipple-
line. If casts which stain brown with iodine are found, they are probably
diagnostic of amyloid change, but the occurrence is too rare to afford much
aid. The diarrhoea occurring in phthisical patients from amyloid disease is
distinguishable from that due to ulceration of the bowel only by concurrent
signs of the degeneration in other organs, and, perhaps, by its even more
intractable character.

Prognosis. — This depends, in most cases, on the chances of removing the
cause of the disease. If suppuration can be checked before the patient is too
exhausted, there is good ground for hoping that the amyloid disease will
spontaneously disappear, the degenerative product being absorbed, and the
cells of the organ resuming their activity. That such recovery may occur in
animals has been proved by an experiment of Lubarsch, who produced the
condition artificially, and demonstrated the presence of amyloid in an excised
portion of spleen. The animal was then allowed to recover from the suppura-
tion which had caused the condition, and when it was subsequently killed
all trace of amyloid substance had disappeared. In renal cases, uncom-
plicated by nephritis, the outlook is best in those due to syphilis, and in
cases in which there is not very much enlargement of liver and spleen. In
patients with pulmonary tuberculosis, the onset of amyloid disease is always
an ominous sign. If the cause cannot be removed no definite limit of time
can be fixed for the duration of life. The condition may last from one
to ten years according to circumstances. In cases of continued suppuration
it is unlikely that the patient will survive more than two years from the
appearance of marked symptoms of amyloid change.

Treatment. — It seems probable that no therapeutic measures avail to
act directly on the amyloid deposit. Efforts should therefore be directed
to removing the cause of the degeneration and improving the general health
of the patient. Cases due to suppuration should be submitted to rigorous
surgical treatment, foci of infection being as far as possible removed by
operation : sequestra should be sought and extracted, cavities scraped out,
and the freest possible drainage provided. In obstinate cases of empyema,
resection of portions of ribs may be necessary to allow the cavity to close
permanently. By such means astonishingly good results may at times be
attained. The patient should be placed in the most favourable circum-
stances possible. Fresh air is essential, that of a bracing seaside climate
being the best of all. The digestive organs must be kept in good order, and
plenty of nourishing food provided. In cases with much nephritis it may
be advisable to exercise some caution with regard to the amount of meat
allowed, and some care is necessary in selecting a suitable climate. Such
cases derive most benefit from residence in a mild winter climate.
The most liberal diet that can be digested is generally permissible. Cod-
liver oil, either alone or combined with one of the preparations of malt, is
of service ; and tonics, such as iron and quinine, are useful adjuvants.

In syphilitic cases the general treatment may be the same, but iodide
of potassium must be given in sufficient doses, rising to 30 grs. three times
a day for adults. The treatment must be continued at intervals for
several (2-5) years. Very good results are often obtainable in these cases,
even when the syphilitic infection is of old standing. Mercury is not of
much service, and must be given cautiously in cases presenting signs of renal
disturbance.

If the cause cannot be removed or directly treated, as is the case in
phthisical patients, it remains only to relieve symptoms. Dropsy may
be treated on ordinary lines by rest in bed and diuretic medicine,

LAKYNX, EXAMINATION OF 329

especially digitalis. Iron is also useful in such cases, the iodide being a
useful salt to employ. Diarrhoea is little amenable to any treatment, and
is a warning of approaching death. Opium or morphia may be tried, com-
bined, if necessary, with sulphuric acid or with sulphate of copper. Astrin-
gents, such as catechu or krameria, may occasionally appear to afford
temporary benefit.

LITERATURE. — 1. Babes. "Ueber albuminose Degeneration," Wien. Iclin. Rundschau,
Nos. 36, 37, Sept. 1898.— 2. Berry, F. M. " The Pathology and Prognosis of Amyloid
Disease," Mag. of Lonol. School of Med. for Women, May 18, 1897, p. 251.— 3. Delepine.
"Classification of Infiltrations and Degenerations," Trans. Path. Soc. of Manchester, Brit.
Med. Joum. Feb. 29, 1896. — 4. Dickinson, W. Howship. " Lardaceous Disease," art. in
Allbntt's Syst. of Medicine, vol. iii. p. 255, and "Diseases of the Kidney," vol. iv. p. 404.
— 5. Krawkow. "De la degenerescence amyloide," etc., Arch, de mid. expir. 1896, p. 134 ;
" Beitr. z. Chemie der Amyloid-Entartung," Arch. f. exp. Pathol, u. Pharmakol. 1897, vol.
xl. p. 195. — 6. Litten. Berl. Iclin. Woch. xv. 1878. — 7. Lubarsh. "Zur Prage der exper.
Erzeugung von Amyloid," Virch. Arch. 1897, ii. 471. — 8. Obrztjt. "Nouvelles recherches
histologiques sur la degenerescence amyloide," Arch, de mid. expir. et d'anat. pathol. 1900,
t. xii. p. 203. — 9. Petrone. "Recherches sur la degenerescence amyloide experimentale,"
Arch, de mid. expir. et d'anat. pathol. 1898, t. x. p. 682. — 10. "Wichmann. "Die Amyloid -
erkrankung," Beitr. z. path. Anat. u. attg. Pathol. 1893, xiii. p. 487.

Laryngismus Stridulus. ^Larynx.

Larynx. — This subject is treated in the following sections: —

1. Examination of.

2. Acute and Chronic Inflammations.

Injuries, Foreign Bodies, etc.

3. Chronic Infective Diseases.

4. Neoplasms — (a) Simple.

(b) Malignant.

5. Neuroses.

Hypertrophy of Lingual Tonsil.

6. Affections of the Cartilages.

Stenosis of the Larynx.

7. Laryngeal Stridor, Congenital.

8. Laryngismus Stridulus.

329

Skiagraphy of Larynx

. 333

332

Palpation

. 333

333

Examination of Trachea

. 334

Examination of Larynx

1. Laryngoscopy

2. Direct Inspection of Larynx

3. Transillumination

1. Laryngoscopy. — The apparatus required for examining the larynx con-
sists of a laryngeal mirror, a forehead reflector, and a good light. As every
senior student nowadays is familiar with the laryngoscopic mirror and
reflector, it is no longer necessary to give a detailed description of them.
But some practical directions as to how to use them, and what to observe,
may be of service : —

The patient should sit erect on a stool or chair with his head slightly
inclined backward. The source of light, whether oil, gas, or electric lamp,
should be placed at his right or left shoulder, and on a level with his ear.
The observer, seating himself in front of the patient, places the reflecting
mirror over his eye nearest to the lamp, so as to screen it from the light,
and looks through the hole in the reflector while keeping both eyes open.
The source of light, the patient's mouth, and the eye of the observer should
be on one level. It is well before proceeding further to make a careful
inspection of the mouth, fauces, and pharynx by means of a tongue-
depressor and the reflected light. Observe if there be any general anaemia
or congestion of the parts, and note the presence of any swelling, ulceration,
cicatrix, or membranous deposit, also any dryness or excess of secretion,
and the condition of the tonsils and uvula. The observations made at this

330 LABYNX, EXAMINATION OF

stage will often help us in the diagnosis of the laryngeal condition, and the
practice which it gives in using the reflector so as to obtain the best
illumination, a great difficulty with beginners, will prove of real service in
the later stages of the examination. Having completed the examination
of the pharynx, we direct the patient to open the mouth widely and push
his tongue well forward. With the aid of a tongue-cloth the tip of the
tongue should be grasped firmly, but gently, between the thumb and fore-
finger of the left hand and held out, but not pulled upon or dragged down
on the lower teeth. The laryngeal mirror should then be held over the
lamp till a slight film of moisture forms on its surface and passes off, and
its temperature tested by applying it to the back of the hand. Next
throw a disc of light on to the fauces, so that its centre corresponds with
the base of the uvula ; and holding the laryngeal mirror in the right hand
lightly like a pen, and with its reflecting surface downwards, pass it quickly
to the back of the mouth, taking care not to touch the tongue or palate in
doing so. The patient, meanwhile, should breathe deeply but quietly
through the mouth, so as to raise the palate and uvula away from the
tongue. The back of the mirror being placed against the uvula, the whole
palate should be raised upwards and backwards by a steady pressure. If
the patient's throat is at all tolerant, the lower edge of the mirror may be
allowed to rest on the back wall of the pharynx, but very often this will
produce retching and prevent an examination.

When the mirror is in position it should be held steadily, while the
handle is carried to the left angle of the mouth, so as to be out of the line
of vision, and by very slightly raising or depressing the hand, so as to alter
the inclination of the mirror, the base of the tongue, epiglottis, and more or
less of the laryngeal cavity should come into view. If the epiglottis is erect
we may at once get a view of the whole larynx and trachea. As a rule,
however, it will be necessary to make the patient sing " eh " or " ee " in a
slight falsetto, so as to raise the epiglottis and expose the larynx.

The examination of the larynx should be conducted systematically,
beginning with the vocal cords, which will at once strike the eye by their
pearly white colour and their movement on phonation and inspiration. Note
in addition to any change in colour, any thickening or irregularity of their
edges, any breach of surface, or the presence of clumps or strands of mucus.
During phonation observe if the cords come together in their whole length,
with their edges tense and sharply defined. Be sure you see right to the
anterior commissure where the cords meet, and follow them backwards to the
vocal processes, which show as yellow spots, or are sometimes pinkish in colour
in voice-users. Observe their position on quiet and deep inspiration, and see
if the amount of abduction is normal and equal on the two sides. Special
attention should be given to the posterior wall of the larynx, the inter-
arytenoid space, which is so frequently the seat of pathological changes. It
is best seen during deep inspiration. Look out for any thickening, irregularity
of surface, or mucous crusts, conditions which interfere with the approxima-
tion of the arytenoids. Just above each cord notice the dark line running
parallel to it, the opening to the ventricle, and immediately above that the
rounded fold of mucous membrane, sharply defined below and sloping away
above into the ary-epiglottic folds, the ventricular band. Compare the two
sides carefully and note any swelling, new growth, or ulceration.

The ary-epiglottic folds should then be inspected, following them down-
wards and backwards from the sides of the epiglottis to the arytenoid
cartilages. Notice their delicate sharp edges above, especially on phona-
tion, and the nodular thickenings corresponding to the cartilages of

LAEYNX, EXAMINATION OF 331

Wrisberg, and the small capitula Santorini seated on the arytenoid car-
tilages. Observe the symmetry of the two sides, look out for any swelling or
cedema, and watch the movements of the arytenoid cartilages on phonation
and inspiration, carefully comparing the freedom of movement of the two
sides. The epiglottis should then be examined. It will be found to vary
greatly in shape and position in different individuals. In some it is broad
and bent forwards towards the tongue, so as to show its posterior surface
only ; in others it is narrow, folded laterally, and inclined back over the
larynx, so that only the anterior surface is seen in the mirror. The
anterior surface is yellowish pink in colour, and has large veins coursing
over it, the edge is more distinctly yellow, and the posterior surface is
pinkish red, deepening in colour towards the prominence at its base, the
cushion of the epiglottis. The edge of the epiglottis should be thin and
sharply defined. Notice if any thickening, cedema, or loss of substance of
its edge is present, or any ulceration of the posterior surface. Next examine
the base of the tongue, between the circumvallate papillae and the epiglottis,
observing the amount of adenoid tissue present (lingual tonsil), and the
numerous large, superficial veins, and conclude with a survey of the lower
pharynx and of the pyriform sinuses which lie outside the larynx between
the ary-epiglottic folds and the inner surface of the thyroid cartilage.

The colour of the laryngeal mucous membrane generally is a pale pink,
like that lining the cheeks, while over the cartilages it becomes slightly
paler, resembling that of the hard palate. It is, however, subject to rapid
variations, and may change from very pale pink to deep red in the course of
a laryngoscopic examination.

To the beginner the partial inversion of the laryngeal image may cause
a little confusion. The only inversion is antero-posteriorly ; the epiglottis
which is seen in the upper part of the mirror appearing farthest away,
while the posterior wall, reflected in the lower part of the mirror, appears
nearest the observer. Laterally there is no transposition, but as the
observer sits facing the patient, what is left from the side of the patient is
to the right of the observer, and vice versa.

The chief difficulties in making a laryngoscopic examination arise either
from nervous apprehension on the part of the patient or from hyperesthesia
of the pharynx. The former, which is more common in women, is best over-
come by assuring the patient that we are only going to make an examination
and not to do anything, and by introducing the mirror for a brief space and
withdrawing it again, even without seeing the larynx. A little patience and
manoeuvring will soon attain our object, whilst any haste or impatience will
only lead to failure.

Local hyperesthesia, so common in men, can be got rid of by the applica-
tion of a 10 per cent solution of cocaine, but the practised laryngoscopist will
only rarely require to employ it for this purpose. By placing the mirror just
in front of the uvula while the patient sings a high-pitched " ee," at other
times by depressing the tongue instead of holding it out, a sufficient view
will be obtained even in the most irritable. As a rule the hyperesthesia of
the pharynx is but another name for the clumsiness of the observer.

The tongue at times causes difficulty by the frenuni being so short as to
prevent its being protruded, or it may be so thick and fleshy as to fill the
cavity of the mouth, or more frequently by a reflex action the dorsum
becomes so arched that the introduction of the mirror is impossible. All
these difficulties are removed by using a tongue-depressor and then intro-
ducing the mirror in the ordinary way.

In a small number of cases the epiglottis lies so far backwards over the

332 LABYNX, EXAMINATION OF

larynx as to prevent a view of its interior. The singing of a high-pitched
" ee," or the making a few rapid and noisy inspirations, will usually suffice
to raise the epiglottis, or a tongue-depressor, such as that of Mount Bleyer
or Schmidt, may be employed to pull forward the root of the tongue. If
these means fail we can paint the larynx with a 20 per cent solution of
cocaine, and then by means of the laryngeal sound raise the epiglottis.

The examination of children, though often easily accomplished, at other
times presents great difficulties. If the child is old enough to understand,
we should try to gain its confidence, and proceed exactly as in adults. Very
young or unruly children should be placed on a nurse's knee, with the legs
fixed between hers, and held erect while the head is steadied by an assistant.
By using a tongue-depressor and quickly introducing the laryngeal mirror,
a view sufficient for the purposes of diagnosis may sometimes be obtained.
Too often, however, the excess of frothy mucus in the lower pharynx and the
rolling together of the epiglottis will defeat our purpose. If it is imperative
to make an examination, we can of course give a general ansesthetic and
employ a gag and tongue-depressor, or we may have recourse to the direct
method of Kirstein. Lack has suggested a method which is specially
valuable in very young children. The tip of the left forefinger is passed
into the right pyriform sinus, and the terminal phalanx hooked round the
hyoid bone, which is pulled forward. A small laryngeal mirror is then
introduced. In children with teeth he uses a curved tongue -depressor
instead of the finger. The younger the child the easier the examination,
and no aneesthetic is required.

There are a number of modifications of the usual method of laryngoscopy,
which enable us to obtain better views of certain parts of the larynx. Thus,
by throwing the head well backwards, and holding the mirror more vertically,
we can get a better view of the anterior commissure, while to see the pos-
terior wall we adopt Killian's position, in which the head is bent forward.
Avellis has described two methods which will be found of value in getting a
view of one side of the larynx, so as to see the under surface of the ventri-
cular bands and into the ventricles. These consist in either bending or
rotating the head towards the side to be examined, while the mirror is
placed at the opposite side of the uvula and held at an appropriate angle.
Thus to examine the right side of the larynx bend the head towards the
right shoulder, or rotate it in the same direction, while placing the mirror to
the left side of the uvula.

2. Direct Inspection. — Under the name autoscopy a method of ex-
amining the larynx and trachea by direct inspection was introduced a few
years ago by Kirstein of Berlin. By means of a specially constructed
tongue-depressor the base of the tongue and epiglottis are pulled forwards
and downwards, whilst light is thrown directly into the larynx from an
electric lamp either attached to the handle of the tongue- depressor or worn
on the forehead. The patient should be seated on a chair with his neck
freed of all clothing, and should bend the upper part of his body forward,
while his head is slightly inclined backwards. The observer standing in
front introduces the spatula, so that its tip catches in the groove between
the tongue and epiglottis, and draws the base of the tongue evenly and
steadily downwards and forwards. Kirstein claims that he can see the
whole larynx and trachea, except the anterior commissure, in about a fourth
of all adults, and that about one-half of all people can be fairly well ex-
amined, so that the posterior region of the larynx is exposed to view. It is
evidently, therefore, not a method to replace laryngoscopy, but where prac-
ticable it is of great value in enabling us to obtain a better view of the

LAKYNX, EXAMINATION OF 333

posterior wall of the larynx and trachea than the laryngoscope gives. It is
a method, however, which requires a very great deal of practice to acquire,
and which calls for considerable endurance on the part of the patient. One
undoubted advantage it has is the ease with which children can be examined
in this way when under chloroform. The head of the child should be drawn
over the edge of the table and held by an assistant. The spatula is then
introduced and the tongue pressed forward in the usual manner ; the head
of the child is then raised or lowered, till the correct position is obtained
which exposes the larynx to view.

3. Transillumination. — If a bright light be concentrated on the side of
the neck, and the laryngeal mirror be introduced in the usual way, a suffi-
cient view of the larynx can be obtained to make out the different parts
more or less distinctly. This fact was observed by Czermak, but not con-
sidered of any diagnostic importance. Voltolini afterwards took up this
method and pursued it with great diligence, employing a small electric lamp
with a water lens as the source of illumination. It can be most con-
veniently carried out by employing the ordinary frontal-sinus lamp, which
is best placed above or below the thyroid cartilage, and either at the side or
in front of the neck. Voltolini expected great things from this method in
the direction of distinguishing simple from infiltrating growths, and in
determining the thickness of laryngeal webs. As a matter of fact it has
little or no practical value, and the experience of Gottstein, that " in no
case does it tell us more than the laryngoscope, but always less," coincides
with that of the great majority of observers.

4. Skiagraphy of the Larynx. — The actual value of the X-ray method in
examining the larynx is still comparatively small. That it enables us at
times to locate more exactly the situation and lie of a foreign body in
the larynx or trachea is beyond doubt. But the hopes which have been
expressed that the infiltration of malignant growths, or ankylosis of the
crico-arytenoid articulations, might be detected by the use of the rays, have
so far remained unfulfilled.

By means of the photographic plate a more or less distinct picture of
the hyoid bone and the laryngeal cartilages can be obtained, but the out-
line of the cartilages is so poorly defined that the diagnostic value of this
method must be very little if any. Ossification of cartilage and fracture of
the hyoid bone are said to have been detected by the use of the X-rays.

5. Palpation. — Through the introduction of laryngoscopy the diagnosis
of laryngeal diseases by the educated finger has become a lost art. A sentence
from Gairdner's Clinical Medicine, published in 1862, is of interest in this
connection. " I am still of opinion," he writes, " that any one who has
accustomed himself to the careful and scientific use of the finger in the
diagnosis of laryngeal diseases will but rarely find his knowledge increased
by the comparatively troublesome and difficult method of laryngoscopy."

Internal palpation is still of value in searching for foreign bodies, and
in determining the size and consistence of growths of the epiglottis, ary-
epiglottic folds, and entrance to the larynx. In young children, too, it may
at times help us to a diagnosis, as in multiple papillomata, which may be
felt when situated above the glottis. The laryngeal sound, introduced
under the guidance of the mirror, enables us to palpate those parts which
are beyond the reach of the finger. It is the first instrument with the use
of which the beginner should become familiar, as it will educate his eye and
hand for the carrying out of all other intra-laryngeal manipulations. It
will be safest for him to practise with Schroetter's sound, which is simply
an English bougie stiffened by having a stout wire run through its centre,

334 LAEYNX, ACUTE AND CHEONIC INFLAMMATIONS

before taking to the finer instruments made of silver, copper, or
aluminium.

The sound is employed to determine the mobility and consistence of
tumours or swellings, to detect fluctuation, to gauge the depth of an ulcer
and find the condition of the underlying cartilage, to hold aside growths or
swellings at the entrance to the larynx, to raise the epiglottis when pendent,
and to test the sensibility of the laryngeal mucous membrane.

External palpation will often be employed in examining the larynx and
trachea. It enables us to determine the amount of lateral displacement of
these organs from the pressure of growths in the neck, and at times to
discover the cause of a stenosis not explained by the laryngoscope. "We may
detect crepitation in fracture or necrosis of the cartilages, and tenderness
and swelling in external perichondritis. In many cases of tracheal obstruc-
tion we can feel the stridor, and locate it better by the fingers than by the
stethoscope. The value of palpation in detecting enlarged glands in syphilis
and malignant disease hardly requires mentioning.

Occasionally it will be found that pain in swallowing, for which no
cause is discovered in the pharynx or larynx, is due to a rheumatic affec-
tion of one of the external muscles, which will be tender on pressure.

6. Examination of the Trachea. — For this purpose a more intense light is
required than for ordinary laryngoscopy. Where the trachea is straight
and the epiglottis erect, we may often get a good view of the anterior wall
and down to the bifurcation, by simply altering the angle at which the
mirror is held. Slight external pressure will often assist in straightening
the trachea, or the same result may be obtained by placing the patient
sideways in a chair, and then rotating his head so as to face the observer.

The most successful method, however, and the only one which gives us
a view of the posterior wall, is that suggested by Killian. The patient,
having loosened all clothing about his neck, should stand with his head
bent forward till the chin touches the sternum. The observer, either sitting
or kneeling before him, reflects the light from below into the mouth. The
laryngeal mirror, of as large a size as possible, should be placed rather
farther forward, and held more horizontally than in ordinary laryngoscopy,
while the soft palate is pushed strongly upwards.

Where tracheotomy has been performed, a view of the under surface of
the cords and of the whole trachea may be got by introducing a small steel
mirror through the tracheotomy wound. By this method growths and
cicatricial webs of the larynx have been discovered, as well as foreign bodies
in the trachea.

Larynx, Acute and Chronic Inflammations

jARYNGITIS

Larynx —

Acute

335

Injuries to

353

Chronic

339

Dislocations of

354

Hypertrophic

344

Foreign Bodies in

354

Membranous

345

Laryngeal Hemorrhage .

356

(Edematous

346

Glottis-

Chronic Subglottic .

348

Congenital Glottic Sten-

Nodular .

349

osis ....

356

Sicca .

351

Pachydermia Laryngitis .

358

Acute, in Children .

352

Blennorrhea ....

359

LARYNX, ACUTE AND CHRONIC INFLAMMATIONS 335

Acute Laryngitis

Synonyms : Acute Inflammation of the Larynx, Cynanche Laryngea,
Angina Laryngea, Acute Catarrh of the Larynx.

Definition. — An acute catarrhal inflammation of the mucous membrane
of the larynx, characterised by hoarseness or aphonia, pain, and cough. It
is, when uncomplicated, without danger to life, and subsides spontaneously
in three to ten days.

Etiology. — Predisposing Causes. — Acute laryngitis is more apt to occur in the
subjects of chronic affections, viz. those with defective digestive, vascular, renal,
or respiratory systems. Over-indulgence in eating and drinking, and what is
termed a "loaded" condition of the stomach and liver, are amongst the most
potent predisposing factors. Defects of circulation naturally make the system
less resisting, and, like affections of the kidney, increase the proneness to local
oedema and catarrh. Amongst the predisposing causes may be numbered gout
and rheumatism.

Acute inflammation frequently attacks the larynx primarily, and then extends
down the trachea. More rarely it may first develop in the bronchi and then spread
upwards. It is so uncommon for acute inflammation of the lungs or pleurae to be
found with a similar condition of the larynx, that the association can only be
looked upon as accidental. On the other hand, it is very usual for catarrhal in-
flammation to make its appearance in the nose and pharynx, and then spread
downwards to the larynx.

Not only does acute inflammatory catarrh frequently start in the nose and by
contiguity spread directly downwards to the larynx, but chronic affections of the
nose and pharynx are amongst the most frequent predisposing causes of acute
laryngitis. For further consideration of the etiological influence of nasal affections
see section on Chronic Laryngitis, p. 339.

Those who lead an indoor or sedentary life, especially in ill -ventilated and
dusty rooms, are much more prone to attacks of acute laryngitis than those who
are occupied with an. outdoor or hardier existence. This tendency is greatly con-
tributed to by the habit of loading the body with unnecessary clothes, wrapping
up the neck, and fearfully avoiding every current of fresh air from the supposed
dread effects of a "draught."

Both extreme youth and extreme age predispose to laryngitis, and in the young
the condition is so important and presents so many special characters that it will
be considered separately {vide " Acute Laryngitis in Children," p. 352). In the
elderly the condition is apt to occur from their diminished powers of resistance.
Men suffer from acute catarrhal affections of the larynx more frequently^ than
women, and this has generally been attributed to their greater exposure to vicissi-
tudes of weather. But, as has just been pointed out, an open-air life in itself is
rather a preventive of laryngitis, and it is much more probable that the affection
occurs more frequently in members of the male sex from their greater self-
indulgence. A very common event is for a patient to pass some hours, stimulated
in many cases with alcohol, in the vitiated atmosphere of a crowded and smoke-
laden room and then go out directly into a cold, and possibly damp air. The cold
air is of course blamed for an attack of laryngitis in which it only played a
subsidiary part.

The disease is more frequently met with in the months of winter and spring.
It is more apt to occur in the subjects of chronic laryngitis.

Exciting Causes. — An attack of acute laryngitis is generally directly attributed
to exposure to cold and wet. This is more operative when there has been a sudden
fall in the temperature associated with increase in the moisture in the air, — such
as occurs in this climate with east winds. Apart from this it may be directly ex-
cited by the inhalation of the irritant fumes of chlorine, bromine, iodine, ammonia,
or of sulphuric, nitric, or other fuming acids. The dust of chromic acid, brick
dust, and similar powders in factories and workshops will give rise to it._ Im-
proper use of the voice— as in the yelling and shouting of street demonstrations —
will often induce acute laryngitis, especially if the enthusiasm has been stimulated
by free indulgence in alcohol. Even without other exciting agents it will some-
times ensue on the vomiting and retching following an alcoholic debauch, and I
have known it to be induced by sea-sickness. The passage of foreign bodies into
the larynx can give rise to acute inflammation, and amongst other traumatic

336 LAEYNX, ACUTE AND CHEONIC INFLAMMATIONS

causes may be mentioned the clumsy introductions of instruments, or the accidental
irritation produced when powders or paints intended only for the pharynx happen
to fall into the glottis. It has been caused by bungling attempts to introduce the
stomach-pump.

It may occur in acute infectious fevers, such as influenza, measles, whooping-
cough, small-pox, typhoid and scarlet fever. Apart from these specific affections,
acute laryngitis is doubtless frequently of septic origin, and is occasionally infec-
tious.

Pathology. — The pathology of acute laryngitis does not differ from that of in-
flammation of other respiratory mucous surfaces. In the first stage there is
hyperemia, with dryness from arrest of the mucous secretion. As this first stage
abates there is increased flow of mucus, mixed with the cast-off leucocytes. There
has been a good deal of discussion as to whether actual ulceration is ever found as
a result of a simple catarrhal process. The defects which are sometimes seen on
the vocal cords are probably more apparent than real, and at the most are only
abrasions of the epithelial surface. The opportunities of post-mortem verification
are too infrequent to settle the point.

The affection may limit itself more particularly to one part of the larynx,
receiving accordingly the name of epiglottiditis, arytenoiditis, chorditis, etc.

Symptoms. — If the laryngitis is due to the spread of inflammation from
the nose or pharynx, the symptoms will have been ushered in with those of
the primary affection.

The onset may be preceded by a feeling of chill or even a slight rigor,
but as a rule the constitutional symptoms are slight. Generally speaking,
the first symptom is discomfort in the throat, and a feeling of fulness
followed by dysphonia or hoarseness. The voice may sound shriller or
slightly falsetto, but it is much more usual for it to sink to a bass, while it
loses its tone. Complete aphonia may occur; and the voice is generally
worse in the morning. Cough is not at all a usual symptom, and if it
occurs in this stage it is short, harsh, and ineffective. There is no expectora-
tion. Talking becomes excessively painful, and often excites the action of
swallowing, which adds to the patient's distress. This dysphagia is more
marked on swallowing merely saliva than on the ingestion of food, and it is
more apt to occur when the inflammation particularly attacks the arytenoid
region.

Indeed there is often the sensation as of a foreign body in the larynx,
producing a constant desire to swallow. This only aggravates the dis-
comfort and spreads the sore feeling upwards towards the ears. There is
seldom any external pain or tenderness, and indeed the firm grasping of
the larynx frequently gives a feeling of support and comfort.

With these local symptoms there may be very little general disturbance ;
in some cases there may be slight feverishness, while in others there is con-
siderable malaise ; but there is never high fever, the appetite is never com-
pletely lost, and the night's rest is rarely destroyed.

At the end of twenty-four to forty-eight hours relief is generally ushered
in by a freer secretion of mucus from the lining membrane, not only of the
larynx, but also of the trachea, which is very commonly affected at the same
time. The voice at once becomes less toneless and loses its hoarse and
harsh character, the dysphagia disappears, and cough, if previously present,
is no longer painful. If not present before, it is now. started by the necessity
of expelling the freely secreted mucus. As this is expectorated a sensation
of rawness is generally referred to the front of the trachea.

With the restoration of voice all feelings of malaise commence to dis-
appear, and if the restored function of vocalisation is not abused the resti-
tutio ad integrum is complete in a few days.

When the larynx is examined with the laryngoscope in the early stage
of this disease, the visible changes may appear slight and insignificant in

LABYNX, ACUTE AND CHEONIC INFLAMMATIONS 337

proportion to the disturbance of voice and the general discomfort. The
vocal cords themselves may show no signs of inflammation, or nothing
beyond a slightly catarrhal surface. The rest of the laryngeal mucous
membrane — that covering the arytenoid cartilages, the ary-epiglottic folds,
the ventricular bands, and the inter-arytenoid space — is at first duskily
injected. This becomes brighter and more marked as the hoarseness
increases, when the vocal cords will be seen to be injected, while their
flat, ribbon -like surface becomes dull and rounded from the infiltration
of the mucous membrane. Owing to the absence of submucous tissue and
the consequent close adhesion of the epithelium to the subjacent tissue, the
swelling and oedema, which may occur in other parts of the larynx, is very
rare here. Although there may be considerable hoarseness without marked
inflammation of the vocal cords, still in acute cases they may entirely lose
their white appearance and become not only pink but so acutely injected as
to assume exactly the same colour as the ventricular bands. In severe
cases the ventricular bands and ary-epiglottic folds are so congested and
swollen as to more or less completely conceal the vocal cords, even on phona-
tion. Part of the aphonia is no doubt due to the inflammation affecting the
subjacent internal crico-arytenoid muscles, and, on phonation, the cords are
seen not to approximate owing to deficiency of the internal tensors. In
other cases this approximation of the cords is due to the swelling of the lax
mucous membrane lying over the inter-arytenoid region. Hsemorrhage
occasionally takes place into the submucous tissue, and blood may even
escape — generally in small streaks only — from the surface. This latter
variety has been termed hmmorrhagic laryngitis. In the first stage the
absence of mucus in the larynx is noticeable. As the inflammation abates
the parts are seen to be bathed in secretion, generally of a muco-purulent
character, which is observed coming up from the trachea and welling over
the inter-arytenoid region to pass into the oesophagus.

The epiglottis is not usually involved in ordinary cases of laryngitis,
although the lower part of the laryngeal surface (the cushion) may present
an injected and velvety appearance.

The appearances of acute inflammation will generally be found at the
same time in the nose and pharynx ; and the mucous membrane of the
trachea frequently shares in the inflammation.

As recovery takes place the cords are restored first to a dirty gray colour,
and then to their normal tint, while they lose their rounded upper surface
and assume their flat appearance. Some paresis of the internal tensors may
be evident for some time, particularly in cases where the voice was not rested
during the illness, or used too soon during convalescence.

Diagnosis. — The diagnosis of acute laryngitis presents very little
difficulty. An examination of the nose and pharynx will exclude other
possible affections ; and the use of the laryngoscope will reveal the exact
condition of affairs. It will be seen that the hoarseness is not due to any
growth or paralytic affection, while the bilateral character of the affection
and its uniform distribution will point to its catarrhal character. The com-
paratively sudden onset of the affection is also a characteristic.

The possibility of a foreign body having entered the larynx should never
be overlooked.

Pkognosis. — When a primary affection, acute laryngitis is free from
danger. Kecovery generally takes place within three to eight days, or else
the condition passes into a chronic affection. It is of graver importance
when it occurs in the aged, the broken down, or as a complication of in-
fectious fevers or systemic conditions.

VOL. vi 22

338 LAEYNX, ACUTE AND CHRONIC INFLAMMATIONS

Treatment. — The treatment may be considered as local, general, and
preventive. The first and most important point in treatment, and one too
often neglected, is the insistence on complete rest for the voice. This
should be as near absolute silence as possible, and even whispering should
be avoided. The custom of attempting to treat a patient's larynx, when
affected with acute inflammation, so as to enable him to sing or speak at
some public function, should be severely discouraged. It is as unphysio-
logical as to allow a patient to walk about with acute synovitis in the knee-
joint. Next to rest of the voice there is little doubt that, whenever possible,
general rest should be enjoined, and the patient is much more likely to make
a rapid recovery if he is put to bed, and treated with a dose of calomel in the
evening followed by a morning saline cathartic. The diet should be light,
but need not be restricted ; alcoholic stimulants and smoking being of course
strictly forbidden. The room should be kept warm but freely ventilated.
The custom of overheating the room, excluding every breath of fresh air,
and filling the atmosphere with the steam from a bronchitis kettle, is only
mentioned to be discouraged. The vitiated air and unnecessary heat can
only depress the recuperative power of the patient, while the clouds of steam
soon condense in chilling damps on his body and bedclothes. Internally,
quinine is frequently prescribed, but I have never seen any benefit accruing
from it, while it often adds to the discomfort of the patient. A few doses
of salicine, say 10 grains every three hours, are much oftener attended with
relief. Tincture of aconite, in drop doses every quarter of an hour until
perspiration is induced, is said to mitigate the severity of an attack.

The action of the skin may be encouraged by warm drinks, diaphoretics,
or the administration of pilocarpine gr. -^ every three or four hours.

In the early stage it is wiser to refrain entirely from direct medication
of the larynx, and all astringents, as well as the use of gargles and the in-
sufflation of powders, should be avoided. Counter-irritation over the neck
and chest by blisters, etc., have generally been discarded, but the gentle
warmth of turpentine liniment over the front of the neck is sometimes
comforting. Cold compresses, frequently renewed, will give relief, or cold
may be applied by means of Leiter's coils. Sucking small pieces of ice will
sometimes relieve the soreness, especially if dysphagia is present. A lozenge
containing codeia gr. ■§■, heroin gr. -J^-, morphia sulph. gr. \, or other sedative
will generally ease the pain and check the useless cough.

The natural history of acute laryngitis shows that discomfort is overcome
as soon as free secretion of mucus takes place, and there can be little doubt
that there is no more soothing application to an inflamed laryngeal mucous
membrane than its own mucus. With this object in view we should order
inhalations of steam, from a jug or specially constructed inhaler containing
half a pint of water at a temperature of 120° F. (65° C), to which has been
added a teaspoonful of compound tincture of benzoin, hemlock, or hops, or
some stimulant oils, such as camphor, oil of turpentine, oil of peppermint,
oil of tar, creasote, and others.

The steam should be inhaled deeply through the nose and mouth for five
minutes every two or three hours. The steam may also be obtained from a
Siegle's spray, the water being medicated with the addition of 2 per cent of
benzoate of soda, or other mucus solvent.

The onset of secretion may be encouraged by sipping hot milk mixed
with Vichy, Vals, or Ems water, or by the administration of small doses of
iodide of potassium.

As the second stage of laryngitis develops the secretion of mucus may be
further encouraged by sucking the trochisci morphias c. ipecacuanha of the

LARYNX, ACUTE AND CHRONIC INFLAMMATIONS 339

British Pharmacopeia, or by the administration of the usual expectorants.
I have found that apomorphine in doses of gr. -^ will prove satisfactory,
or the following prescription : — R; Ammon. chloridi grs. iv., Spirit, ether,
nitrosi m\xv., Syrup, scilla? il^xx., Syrup, tolut. ad 3j. Ft. Dosis. Sig. : A tea-
spoonful in water every three or four hours. Small repeated doses of iodide
of potassium undoubtedly promote secretion ; and vinum antimonialis is a
useful drug either in combination with the iodide or given separately.

As the acute stage passes off these " vapores " may be superseded by the
sprays of liquid vaseline — known under various names as paroleine, albo-
leine, cimoline, benzoinol, etc. — either plain or with the addition of menthol,
camphor, eucalyptus, oleum gualtherium, oil of peppermint, tar, creasote, etc.

As soon as the acute symptoms are past, the sooner the patient gets out
of doors again the better. The use of the voice should be resumed with
care, as otherwise a condition of chronic laryngitis may be set up. If there
is left a want of tension in the cords this can be improved by the administra-
tion of strychnine or nux vomica, or by the use of electricity and massage.

As in a large majority of cases there is considerable catarrh of the nose
and pharynx, great relief can be obtained by cleansing the nasal fossae and
post-nasal space with a warm alkaline solution. Some of the various modi-
fications of Dobell's solution will be found suitable for this ; or simply 5
grs. to the ounce of either borax, bicarbonate of soda, or table salt will be
found sufficient. The addition of a small quantity of cocaine hydrochlorate,
about gr. -^ to the ounce, is very comforting, and in such a small proportion
is without risk, except in children, in whom it should be entirely avoided.
This cleansing is best effected with the post-nasal syringe, but it can be
done with an ordinary anterior nasal syringe or coarse spray.

The methods of prevention have been indicated in what has been already
said. Moderation in the use of alcohol and tobacco, the avoidance of dusty,
crowded, and overheated rooms, misuse of the voice, and observation of the
ordinary rules of hygiene, should be enjoined. Locally, any chronic affections
of the air-passages should receive attention.

Chronic Laryngitis

Synonyms : Chronic Catarrh of the Larynx, Chronic Inflammation
of the Larynx, Chronic Laryngeal Catarrh.

Definition. — A chronic catarrhal inflammation of the mucous mem-
brane of the larynx, the chief symptom being alteration and impairment of
the voice.

Etiology. — The mucous membrane of the larynx is the part of the respiratory
passages which is least seldom the primary or sole seat of chronic inflammation.
Except, perhaps, in the case of professional voice-users, it is quite exceptional to
find idiopathic chronic laryngitis. There are probably two causes which explain
this observation. One is that the arrangements in the nose and naso-pharynx are
so perfect for protecting the organism from deleterious conditions of the atmo-
sphere, that the inspired air is in the most suitable conditions as regards warmth,
moisture, and filtration before it reaches the vocal cords. The second reason is
possibly that the non-vascularity of the vocal cords themselves and the scai-city of
glands in the larynx are both conditions which would lend little foothold to chronic
catarrhal processes, in the absence of other causes contiguous or constitutional.

Disorders of the nasal and post -nasal cavities, and to a less extent of the
pharynx and mouth, are the most potent factors in the origination of chronic
laryngitis. The importance of nasal respiration is now so generally recognised
that it is sufficient to call attention to the deterioration which must occur in the
pharynx and larynx from chronic mouth -breathing. By its passage through the
nasal fossse the current of air is charged with moisture, raised to the temperature

340 LARYNX, ACUTE AND CHEONIC INFLAMMATIONS

of the body, and filtered from dust and other gross impurities.1 In ordinary con-
ditions it is also deprived of the micro-organisms which float in it, the greater
number being arrested at the very entrance of the nostrils, while those which
penetrate further are enclosed in the nasal mucus, which is inimical both to their
development and to their further penetration. The leucocytes also help in resist-
ing bacterial invasion, while the ciliated epithelium rapidly removes the arrested
organisms.2

Now chronic catarrhal affections by narrowing the calibre of the nasal chambers,
diminishing or altering the secretion of their mucous surfaces, and destroying the
properties of the ciliated epithelium, interfere with these physiological safeguards.
The inspired air then impinges directly on the pharynx and larynx, and being cold,
dry, and unfiltered, it deposits its impurities on these surfaces, which it robs of
warmth and moisture. There are not in the pharynx any arrangements similar to
those in the turbinal bodies of the nose for the protection of the organism, and
consequently its mucous membrane becomes dry, congested, and chronically
inflamed.

Besides thus influencing the properties of inspired air, nasal and pharyngeal
affections also predispose to chronic laryngitis by the possible spread of catarrh by
direct continuity of tissue, and by the septic and irritant matter which may find
its way directly into the larynx. Chronic nasal troubles also predispose to laryn-
gitis by the " hemming " and hawking which they sometimes excite, and also by
interfering with one of the chief resonating cavities of the voice. In this way
increased strain is thrown on the laryngeal muscles, and catarrh and paresis are
more easily induced.

Chronic laryngitis may be the consequence of chronic catarrh of the trachea
and bronchi. Whether this is the result of direct propagation, or is due to the
coughing produced and the straining efforts necessitated to expel the mucus, it is
certain that it is a much more common cause than in the acute affection. Many
cases of laryngeal catarrh are overlooked from a neglect to examine the chest for
emphysema and chronic bronchitis. An inveterate form of laryngitis sometimes
precedes the development of any physical sign of laryngeal or pulmonary tuber-
culosis.

Any inflammatory or ulcerative processes in the mouth, uncleaned or carious
teeth, and pyorrhoea alveolaris, are also conditions which may be etiological factors
in the disease.

Diathetic or visceral disorders are frequent causes of catarrh of the upper air-
passages. Thus gastro- intestinal, hepatic, cardiac, and even renal defects will
either directly cause catarrh, or will produce a reflex cough, which in its turn and
through its persistency sets up chronic inflammation. The same may be said for
rheumatism and gout, the former producing a painful and the latter a very per-
sistent form of laryngitis. All the direct or reflex causes of cough may be claimed
as productive of laryngitis, in that the cough will itself induce a laryngeal catarrh.
It may form part of an attack of asthma or hay-fever ; and has been traced to
frequent fits of weeping.

Excessive, and more particularly faulty, use of the voice is a potent factor in
production of chronic laryngitis, particularly in those who are predisposed by any
of the conditions already mentioned.

The chronic affection very frequently dates from an attack of acute laryngitis,
especially if the patient has not rested the voice carefully during the illness, or has
returned too soon to his use of it, or to unsanitary surroundings.

All ages are subject to this affection, although it is more commonly met with in
adult life. . Both sexes may be affected, although men, from exposure to the causes
already enumerated, are more prone to it than women. Women are said to be
more subject to it if exposed to any of the exciting causes during the period of
menstruation. John Mackenzie has drawn attention in an interesting study to
the relationship between disorders of the sexual system and affections of the larynx.3

Some drugs, and particularly iodide of potassium, will produce a laryngeal
catarrh which might be mistaken for chronic laryngitis. With sensitive subjects
the inhalation of certain odours are even sufficient to induce an attack.4

1 Aschenbrandt : Die Bedentung der Nase fur die Atmung, AViirzburg, 1886 ; Kayser, " Die
Bedentung der Nase fur die Respiration," Pfliiger's Archiv, Bd. xli. 1887 ; Bloch, "Zur Physio-
logie der Nasenatmung," Zeitschrift f. Ohrenheilk. Bd. xviii. 1888 ; MacDonald, Respiratory
Functions of the Nose, London, 1889 ; Sehiitter, Annates des mal. de Voreille, April 1893.

2 StClair Thomson and Hewlett, Lancet, January 1896.

3 John Mackenzie, Joum. of Laryng. March 1898.

4 Joal, Revue de laryngol. 1894.

LARYNX, ACUTE AND CHRONIC INFLAMMATIONS 341

As a secondary phenomenon chronic laryngitis is nearly always present in long-
continued diseases of the larynx, such as tuberculosis, lupus, syphilis, leprosy,
paralysis, and in the formation of new growths, simple and malignant.

Amongst the general external conditions which give rise to chronic laryngitis
the reader is referred to the article on the acute form. It is here sufficient to
recall that the chief enemies of the larynx are dust, alcohol, and tobacco.

Pathology. — In this affection there is permanent hyperemia of the blood-
vessels from long-standing irritation. There is small -celled infiltration of the
submucous tissues. The epithelium may be abraded in parts. In many cases
there is a certain amount of myositis, owing to the proximity of the intrinsic
muscles to the mucous surfaces. The mucous glands are stimulated into increased
flow of a thick, tenacious secretion, but it is hardly likely that the racemose glands
should be so exclusively affected as to justify the description of a separate variety
under the title of glandular laryngitis, as has been done by the older authors.

Symptoms. — The constant, and sometimes the only, symptom complained
of is the alteration of the voice. This is husky at first, with intervals when
it may somewhat suddenly and unexpectedly resume its natural clearness,
but as the affection becomes established the hoarseness is more persistent.
The tone of the voice is always lowered, and the vocalisation becomes
harsh. Aphonia is seldom complete, except after prolonged or extreme
forcing of the damaged organ. The hoarseness is more marked after a rest,
or on rising in the morning, and tends to disappear after a little use. But
if this restoration of voice is at all freely made use of, the hoarseness tends
to become worse than before, and in any case it is apt to recur later in the
day.

The patient is conscious of the increased effort which is made in vocalisa-
tion, and this produces a sense of fatigue and soreness in the throat. There
is not necessarily any cough, but constant " hemming " and hawking in the
efforts to clear the larynx of the sticky mucus which hangs about the
affected parts. Abundant expectoration generally indicates that the trachea
and bronchi are affected with the same catarrhal process. Cases have occurred
of profuse catarrh from the larynx, to which the term laryngorrhoea has been
applied.

The alterations in voice are more noticeable in women and in tenor
voices, than with baritones or basses. That is to say, a condition of laryngeal
catarrh which would cause a decided change in the speaking voice of women
and tenors might hardly be noticeable in a bass, and would probably not
prevent him from singing with his usual success, at least for a while.

In a considerable number of cases the patient will also present the
symptoms of concomitant nasal or pharyngeal catarrh.

Examination. — The laryngoscope will reveal some variety in the condition
according to the duration and severity of the case and the parts principally
affected. In all cases there will be certain constant conditions observable. For
instance, there will be an absence of acute inflammation, and the changes will
generally be bilateral and more or less symmetrical.

The mucous membrane has a congested appearance, the colour varying accord-
ing to the subject — being frequently darker and more purplish in basses and in
the more chronic cases, while it is apt to be redder in female voices and in tenors.
Pellets of mucus are frequently seen, generally hanging about the inter-arytenoid
space, the vocal processes, or the ventricular bands, and more rarely on the anterior
two-thirds of the vocal cords. The cords themselves in many cases are only slightly
affected, appearing only dull or a dirty gray in colour. At other times arborescent
vessels are seen ramifying on them. (In the normal condition no blood-vessels are
to be seen on the vocal cords in the same way, for instance, that they are met with
on the epiglottis.) In the worst form the cords may assume a dull deep red colour.
Their surface is generally more rounded, and on phonation it is seen that their
approximation is frequently incomplete, either from paresis of the internal tensors
of the cords or from the mechanical obstruction presented by thickening in the
inter-arytenoid space.

342 LABYNX, ACUTE AND CHBONIC INFLAMMATIONS

Shallow abrasions of the epithelial surface are sometimes met with, especially
towards the inter-arytenoid region. The ventricular bands share in the general
congestion, and it is frequently seen on phonation that they are considerably
thickened. This may be due to small-celled infiltration or to muscular hyper-
trophy from vicarious action of the false vocal cords — the pain or inefficacy of the
true vocal cords being supplemented by forcible adduction of the ventricular bands.
The ary-epiglottic folds share in the process, and the epiglottis shows increased
vascularity and sometimes thickening of the petiolus.

Storck has described a fissure as particularly apt to occur amidst the folds of
mucous membrane in the inter-arytenoid space when they are pressed together in
phonation.

Diagnosis. — The chronic nature of the affection, the absence of consti-
tutional symptoms, and the bilateral and generally symmetrical nature of
the affection are usually sufficient to remove any difficulty in the way of
diagnosis. Particular care should be taken in excluding the possibility of
early tubercle, as this disease is often preceded by a laryngitis of a very
inveterate character. The presence of marked anaemia of the air-passages,
or any marked constitutional changes, should lead to a careful examination
of the temperature, chest, sputum, etc.

Prognosis. — Once established, this affection shows little tendency to
spontaneous resolution. In many instances the exigencies of their profession
prevent patients from giving the necessary rest to their voice, while in others
the drawbacks of their surroundings render a complete cure impossible. In
some patients the defects in their upper air-passages may have been over-
looked in youth, and so have left behind conditions which are irremediable.
In others, again, faulty methods of singing or voice production have become
too ingrained to be eradicated.

There is no danger to life in the affection, but the promise of a spon-
taneous cure in a well-established case is too remote to be taken into
consideration. On the other hand, appropriate treatment will lead to
recovery in a large number of cases, especially if the patient is willing and
able to carry out advice.

Treatment. — Success in the treatment of chronic laryngitis will princi-
pally depend on the successful detection of the chief etiological factors, and
it is surprising how often these will be found outside the larynx itself.
The removal of the primary causes is the important point ; topical applica-
tions, although helpful, fill a secondary role. Thus attention to the digestive
functions or the action of the kidneys, the regulation of uterine disturbances,
the detection of gout and rheumatism, may in some cases be the chief indica-
tions for treatment. The customs of the patient as regards food, drink,
clothing, sleep, exercise, tobacco, fresh air and ventilation, may require atten-
tion. In a large number of cases — the majority, according to Bosworth x —
treatment will have to be directed to the nose or naso-pharynx. Any morbid
process, or marked structural variation from the normal, should be attended
to (see " Nose "). When the principal cause is found — possibly by a process
of elimination— to be in the larynx itself, it will generally be discovered
that the laryngitis is attributable to faulty use of the voice. It is more
misuse than over-use which is responsible for chronic laryngitis, and in many
cases it will be found necessary to see that the patient acquires a proper
method of voice-production and singing. In most cases, however, treat-
ment should generally begin by rest to the affected parts, and this is only
secured by strict silence.

For those to whom this is an impossibility all shouting, public speaking
in the open air, lecturing in close, crowded, dusty, or stuffy rooms should

1 Diseases of the Nose and Throat, 3rd ed. 1897, p. 625.

LAEYNX, ACUTE AND CHRONIC INFLAMMATIONS 343

certainly be avoided, and the use of the voice limited to the bare necessities
of the patient's surroundings.

It is so seldom that the necessities for talking imposed by the ordinary
duties of life allow of strict silence, that, for those who can afford it, it is
doubtless wiser to go away for a change. Besides, there can be no more
natural healer for a chronically inflamed larynx than pure air. Any
country air is doubtless better than the air of cities, but general experience
has shown that the high, dry air of mountains is apt to be too irritating,
and that for an inflamed larynx it is better to choose milder and softer
climates, such as those of Madeira, Palermo, Pisa, or the south-westerly
coasts of our own shores. There is some difference of opinion, and also of
idiosyncrasy, with regard to sea air, but it is fairly certain that strong winds
are prejudicial, and that the shelter from them afforded by woods — especially
pine woods — is a distinct desirability.

When there is much mucus about the larynx any local treatment should
be preceded by a cleansing alkaline spray, such as bicarbonate of soda, borax,
salt, either alone or in combination with one another, or with chlorate of
potash, salicylate of soda, sugar, etc.

By some it is recommended that these sprays should be used warm, but
Moritz Schmidt points out that warm sprays to the nose and throat for
chronic conditions only lead to further passive congestion and foster catarrh,
whereas the cold spray is not only harmless but much more bracing and
stimulating. These sprays may be rendered more soothing where there is
cough or discomfort by the addition of a small quantity of cocaine. In the
strength of one grain to the ounce there is no risk in placing it in the hands
of a patient, or fear of its starting the cocaine habit. Antipyrine (grs. v. to
the oz.) or carbolic acid (grs. ii. to the oz.) also have a sedative action, and
if the sprays are made up with fresh peppermint water they are rendered
both more pleasant, more soothing, and more antiseptic. A stimulant
effect can be produced by the addition of menthol (gr. i.), eucalyptus, oleum
gualtherium, oil of cassia, or pine oil.

Or any of these oils can be sprayed into the larynx when made up with
a basis of liquid vaseline (paroleine, alboleine, cimoline, etc.). These oily
sprays have to a large extent superseded the steam inhalations which were
formerly employed for carrying the essential oils into the air-passages.

It may be found necessary to make use of astringents in inveterate
cases of chronic laryngitis. This is best done in the form of laryngeal
sprays, to which are added one or other of the following : — Nitrate of silver
(2 grs. to 5 grs.), sulphate of zinc (grs. v. to grs. x.), chloride of zinc (grs. ii.
to vi.), perchloride of iron (3 grs.), sulphate of copper (grs. iii. to x.) to the
oz. Massei recommends a 2 per cent spray of lactic acid.

If the secretion is thick and tenacious it may be loosened by pastilles of
chloride of ammonia and benzoic acid.

Astringents may be employed in the form of powders insufflated into
the larynx, but as they are quickly expelled it is doubtful if their action is
ever other than that of a stimulant. Gargles need only be mentioned to be
condemned as useless.

The laryngeal brush is nowadays seldom resorted to. In a large
number of cases, even when applied with the greatest skill, it produces such
an amount of spasm and local reaction, and runs such a risk — from move-
ment on the part of the patient — of local traumatism, that the drawbacks
attendant on its use far outweigh the benefits to be derived from it. If
cocaine is required before each application the disadvantages of the cocaine
may counterbalance the medicinal advantages of the pigment. It may be

344 LARYNX, ACUTE AND CHRONIC INFLAMMATIONS

required in some inveterate cases, and then we generally make use of nitrate
of silver, beginning with a solution of the strength of 10 grs. to the ounce
and increasing it gradually, according to the local reaction produced, upwards,
till a strength of 100 grains to the ounce is reached. It has been recom-
mended that the application should be made daily, but there are few cases
in which an application once a week is not sufficient. The frequency must
be proportionate to the local condition and to the reaction produced. In
milder cases chloride of zinc may be used in solutions of the strength of 20
or 30 grs. to the ounce. It has been advised to treat any varicosity in the
vocal cords by applications of fused chromic acid, and Krause recommends
in chronic cases minute longitudinal incisions into the cords with a suitable
laryngeal lancet. Such dangerous proceedings are uncalled for, and it is
seldom that milder measures will not secure better results.

Finally, many cases of chronic laryngitis can be greatly relieved, in
persons who can afford it, by a suitable change of climate, and particularly
by a visit to such spas as Ems, Mont Dore, Eaux Bonnes, Marlioz, Challes,
Cauterets, etc.

Any remaining paresis of the muscles may be met with doses of
strychnine or the use of electricity.

Elderly patients who are subject to winter attacks of chronic laryngitis
should be recommended a change to a warmer climate.

Hypertrophic Laryngitis
General Hypertrophic Laryngitis

Definition. — A form of chronic laryngitis in which the lining mem-
brane of the larynx is more or less uniformly thickened.

Etiology. — A reference to the article on chronic laryngitis will show
that when long continued there is a tendency to overgrowth of the mucous
membrane, more marked in certain regions than in others. All the causes
which have been detailed as productive of chronic catarrh of the larynx,
are also operative in producing chronic general hypertrophic laryngitis. The
latter form is, however, more apt to be met with when the chronic condition
has been neglected for some time, and the use of the voice has been insisted
on, or the external causes have not been removed. Hence the condition is
very frequent in such occupations as that of a street hawker, or those who are
exposed to the irritation of dusty occupations.

It is particularly apt to occur in patients who, in addition to the usual
causes, indulge freely in alcohol. It is frequently met with in syphilitic
subjects, in whom the process does not show any distinct specific character,
and may, in fact, manifest great resistance to the influence of syphilitic
treatment.. This has been termed para-syphilitic 1 laryngitis.

Symptoms. — For a description of the symptoms the reader is referred to
the section on chronic laryngitis (p. 341). In the chronic hypertrophic
variety the change of voice is more marked ; there is less tendency to cough ;
and, although subject to acute or sub-acute exacerbations, the patient suffers
less in using his chronically husky and toneless voice.

Examination. — In addition to the general condition described under the
heading of Chronic Laryngitis (q.v.), the laryngoscope reveals the thickening
which has occurred in the mucous lining of the larynx. This is found most
commonly in the inter-ary tenoid space/'where the hypertrophied mucous mem-
brane may be heaped up into one central mass, though through the frequent

1 Massei, Annates des mal. de Voreille, vi. No. 2, 1899.

LAUYNX, ACUTE AND CHKONIC INFLAMMATIONS 345

approximation of the vocal processes in phonation it has more commonly
been folded and so divided into three or more heaps. These are symmetri-
cal, neither inflamed nor ulcerated, and generally of the same colour as that
of the mucous membrane usually found in the inter-ary tenoid space. The
surface may be rough, but is uniform, and in many cases is coated with
sticky mucus. On phonation this overgrowth is seen to be compressed
between the posterior ends of the vocal cords, and by interfering with their
approximation causes huskiness.

In other instances, or in addition to the above, the hypertrophy is found
on the ventricular bands, which may be so much thickened as to more
or less completely conceal the true cords. This is particularly apparent on
phonation, and indeed much of this hypertrophy is possibly muscular and
due to the ventricular bands having been called into action to support or
replace the inflamed or fatigued true cords.

The arytenoid region and the ary-epiglottic folds may also be chronic-
ally thickened. Hypertrophy of normal tissue is rarely found on the
epiglottis.

Peognosis. — Very slight improvement is to be expected without treat-
ment. Strict rest of the voice is seldom secured, and only too often a
return to voice use, or exposure to the primary irritating causes, will induce
a recrudescence of the affection. That form which has been referred to as
para-syphilitic laryngitis gives rise to one of the most inveterate forms of
hoarseness {vide " Syphilitic Laryngitis "). Considerable improvement can
be secured when due to other causes, provided the patient will carry out
the somewhat tedious treatment, a treatment which may also entail con-
siderable expense from the enforced rest to the voice.

Tkeatment. — Eeference should be made to the section on the treatment
of Chronic Laryngitis (p. 342). In the hypertrophic form the treat-
ment has to be more persevering and more thorough. It is in this variety
that application of caustics on the laryngeal brush find their chief indica-
tion. In a few cases it may even be necessary to remove portions of the
hypertrophy when it is situated in the inter-arytenoid space. In other
regions of the larynx surgical interference is seldom called for.

For patients who can afford it, the method of treatment carried out at
Ems, Mont Dore, Marlioz, and similar health resorts is particularly useful in
this form of laryngitis.

Membranous Laryngitis, Non-diphtheritic

Synonym : Fibrinous Laryngitis.

Definition. — An inflammation of the mucous membrane of the larynx,
accompanied by the formation of a membrane, and not caused by the Klebs-
Loeffier bacillus. It is associated with the presence of various other micro-
organisms. It may be acute or sub-acute.

Etiology. — The occurrence of a false membrane in the larynx is not
frequently observed, and when the cases in which it is of diphtheritic origin
are excluded, it may be said to be a very rare affection.

It may be due to the application of strong caustics to the larynx, and
has been caused by traumatism or the inhalation of boiling steam or irri-
tating vapours.

In some instances it is of undoubtedly septic origin, the micro-
organisms which are apparently causative being various staphylo- and
streptococci. The membrane presents the same naked-eye and microscopic

346 LAEYNX, ACUTE AND CHEONIC INFLAMMATIONS

appearances as in diphtheria, but it is not — as frequently in that affection
— found in the pharynx or nose.

Symptoms. — Hoarseness, a croupy cough, and other laryngeal symptoms
indicate the region attacked. Dyspnoea may appear early in acute cases,
but be little marked in those in which the membrane forms slowly. Con-
stitutional symptoms will depend entirely on the causative factor ; but as a
rule there is not the early and grave depression which is generally character-
istic of diphtheria.

Examination will show the presence of a grayish white or dirty gray
membrane on the vestibulum laryngis, or even on the true vocal cords. If
due to the bacillus pyocyaneus it may be of a blue colour. It will be found
to be closely adherent to the mucous surface.

Diagnosis. — The principal affection from which this form of mem-
branous laryngitis must be diagnosed is diphtheritic laryngitis. The latter
in the majority of cases is associated with the presence of membrane in the
pharynx as well as the larynx ; the Klebs-Loemer bacillus can be cultivated
from a swab taken from the membrane ; and the constitutional symptoms are
more marked. Membranous laryngitis, in fact, is a local affection causing
some general disturbance ; but diphtheritic laryngitis is a general systemic
infection from laryngeal inoculation. When there is any doubt as to the
diagnosis, it is safer to treat the case as if it were one of true laryngeal
diphtheria.

Prognosis. — This will depend upon the cause of the affection ; on the
amount of constitutional reaction ; and on the degree of interference with
respiration. The prognosis becomes grave when imperfect aeration of the
blood is observed, or when cyanosis develops.

Treatment. — The treatment should be symptomatic and will be con-
ducted on the lines indicated in the section on acute laryngitis. When the
respiration is interfered with, either intubation or tracheotomy may be
required.

(Edematous Laryngitis

Synonyms : Laryngitis Phlegmonosa, Erysipelas of the Larynx, (Edema
of the Glottis, (Edema Glottidis, (Edema of the Larynx.

Definition. — A certain amount of sub-acute or passive oedema is apt
to occur in many of the ulcerative processes in the laryngeal mucous
membrane — syphilitic, tuberculous, malignant — as well as in connection
with other affections. But, as generally understood by many, the term is
reserved for an acute oedematous infiltration of the tissues bounding the
upper larynx, more particularly the ary-epiglottic folds and the inter-
arytenoid region, and dependent on the following causes : —

Etiology. — Acute oedema may be induced by the following causes : — The im-
paction of foreign bodies in the larynx, the inhalation of boiling steam or liquids
(as when children drink from the spout of a kettle or teapot), the drinking of
scalding or corrosive fluids, the inhalation of very irritating smoke or chemical
vapours, or the injudicious or accidental application of caustics to the larynx.
Many of the causes which produce acute laryngitis may also excite oedema, but it
is rare to find it dependent only on excessive voice use. It may accompany the
acute laryngitis of the infectious fevers — measles, scarlatina, diphtheria, enteric,
erysipelas, whooping-cough.

Inflammation in the neighbourhood of the larynx, as in malignant disease of
the oesophagus, peritonsillar abscess, inflammation at the base of the tongue, etc.,
may lead to oedematous infiltration of the laryngeal mucous membrane. It may
accompany Bright's disease, diabetes, cardiac anasarca, Quincke's oedema (angio-

LARYNX, ACUTE AND CHRONIC INFLAMMATIONS 347

neurotic oedema), and myxoodema. It is sometimes produced by iodide of
potassium, and even by small doses in susceptible subjects.

One of the most dangerous forms is that dependent on septic infection and
often met with in the course of Ludwig's angina, phlegmonous sore throat,
erysipelas of the pharynx or larynx, and similar septic infections.

(Edema of the larynx has been met with in hydrophobia, and as an early com-
plication of typhoid fever.

Any growth comprising the tributaries of the superior vena cava, suchas
goitres, bronchial glands, and mediastinal growths, may lead to passive congestion
of the lai-ynx.

Pathology. — The loose attachment of the mucous membrane to the underlying
tissues in the neighbourhood of the ary-epiglottic folds, the inter-arytenoid region,
and the ventricular bands, readily allows these parts to be infiltrated with serous
effusion. Owing to the close attachment of the mucous membrane over the vocal
cords and epiglottis these regions are more rarely affected. The researches of
Hajek have demonstrated anatomically how it is that oedema of the larynx does
not readily spread across the middle line from one side to the other of the larynx,
or from the front to the back of the epiglottis.1 The oedema may affect chiefly or
entirely the subglottic region. The exudation varies according to the cause and
severity of the affection. In the passive form it is entirely serous, but in the
septic and inflammatory form it is sero-purulent or purulent.

Symptoms. — In the chronic forms — those due to passive oedema — the
symptoms develop gradually. The patient has a feeling of fulness and a
sensation as of a foreign body in the throat ; there is some dysphagia, and
from the accumulated mucus and froth about the sinus pyriformis and
base of the tongue, the voice becomes thick and hoarse. In the acute septic
form the suddenness and severity of the symptoms are very characteristic
of oedematous laryngitis. They are often ushered in by a rigor. Dyspnoea
is generally an early symptom and may become acute within a few hours.
The voice becomes aphonic, and there is great pain and little result in the
attempts to clear the larynx of mucus, while great distress is occasioned
by any efforts at swallowing it. The pulse is small and quick, there is
frequently very great anxiety, and the face, which is bathed in clammy
sweat, becomes congested or palely cyanotic.

On examination with the laryngoscope, if a view of the larynx is
obtainable, the most striking feature is the prominence of the large
oedematous swelling of the ary-epiglottic fold on each side. These may be
of a dull purple colour, but more frequently they are pale and passively
congested. They are either so large or so coated with mucus that an
inspection of the interior of the larynx is only occasionally possible, but
when this is obtainable the ventricular bands are found to share in the
process. If the epiglottis is attacked it will be prominent, inflamed, swollen,
and somewhat globular or turban-shaped. If the subglottic region is
involved a uniform red swelling will be seen below each vocal cord. In
some cases there will be the symptoms of the causative conditions.

Diagnosis. — When there is a history of a distinct cause, and the onset
of the symptoms is sudden and acute, the large pale translucent swellings
are typical of oedematous laryngitis. There is more difficulty when the
history is obscure and when the condition is grafted on some chronic condi-
tion, such as tuberculosis.

Peognosis. — This will depend on the cause. Speaking generally, oedema
is always a serious condition, except in the instances where it is caused by
iodide of potassium, angioneurotic oedema, or other causes in which it is
seldom severe. Occurring in the later stages of tuberculosis and malignant
disease, it is of serious augury. It is one of the most fatal incidents in

1 Langenbeck's ArcMvfilr hlinische Chirurgie, Bd. xlii. Heft 1.

348 LABYNX, ACUTE AND CHRONIC INFLAMMATIONS

septic infection of the pharynx and neighbouring tissues. The possibility
of sudden spasm must not be forgotten.

Treatment. — The treatment will be to some extent guided by the
discovery of the cause ; for instance, the presence of an impacted foreign
body might at once determine a tracheotomy. In any case the oedema
must be relieved. If moderate in amount and not sufficient to cause
marked laryngeal stenosis, this may be done by sucking ice and the appli-
cation of ice-bags or cold-water coils to the neck. Hypodermic injections
of pilocarpine (gr. -J) have given excellent results. Spasm may be mitigated
by bromide of potassium and chloral. The oedema produced by iodide of
potassium will disappear more quickly if bicarbonate of soda is freely
administered. When the oedema is more threatening it should be reduced
by freely scarifying the infiltrated tissues, previously cocainised, under the
guidance of the laryngeal mirror. When the stenosis is very acute, the
symptoms threatening, or the cyanosis increasing, tracheotomy should be
performed. Indeed, in all decided cases the necessity of tracheotomy, which
may suddenly declare itself, should always be borne in mind. Quinine, and
the tincture of the perchloride of iron in large doses, have been recommended
in the septic form, and injections of antistreptococcic serum might be tried.

Chronic Subglottic Laryngitis

Synonym : Chorditis vocalis inferior hypertrophica.

Definition. — A variety of chronic hypertrophic laryngitis characterised
by overgrowth or infiltration of the region immediately below the vocal
cords.

Etiology. — This form of laryngitis is traceable to the same causes which have
been given in describing the diffuse form. Possibly the over-use or misuse of the
voice is not such an evident factor as in the other forms of laryngitis. It has
been recorded as a sequela of enteric fever.1

Symptoms. — This form of laryngitis will manifest itself by the train of symptoms
which have already been described under chronic laryngitis (p. 341) and chronic
hypertrophic laryngitis (p. 344). The symptoms which particularly characterise
it are the presence of marked dyspnoea, a metallic ring to the voice, and a short,
sharp cough similar to that heard in obstruction of the trachea. There may be
greater hoarseness and impairment of the voice. The dyspnoea will vary accord-
ing to local conditions and also from time to time, but it is frequently sufficient
to cause an alarming sense of suffocation, and not infrequently necessitates active
relief.

Pathology. — Some recent microscopical observations (by Sokolowski and
Kuttner) describe the disease as consisting of chronic cell proliferation, both in
the mucous membrane and in the submucous and muscular tissues. It may
spread as far as the margins of the vocal cords, and gradually develops into a hard
indurated mass.

Examination. — The laryngoscope shows that the hypertrophy is chiefly, if not
entirely, limited to the subglottic region, where two uniform, rounded, symmetrical
swellings present themselves, more or less closing up the glottic space below the
level of the vocal cords. Each swelling presents a margin parallel to the vocal
cord above it, and at first sight gives the suggestion of a second and inferior vocal
cord. Not only do these two swellings encroach on the glottic chink and so pro-
duce dyspnoea, but on phonation it is seen that they considerably impair the
complete approximation of the cords and so interfere with the voice.

The colour may be of the translucent, grayish-white character met with in
nasal polypi, and in these cases, if examined with a laryngeal probe, the thicken-
ings will sometimes be found to be oedematous. In other cases they are solid, and
the colour varies from dull catarrhal pink to vivid congested red.

1 Sokolowski, Archivfiir Laryngol. Bd. ii. Heft 1, 1894.

LAEYNX, ACUTE AND CHEONIC INFLAMMATIONS 349

Diagnosis. — With increased precision in diagnosis this affection, as a
primary disease, has become rarer. There was always considerable doubt as
to its exact pathological nature, and in many cases it is doubtless due to
tuberculous or syphilitic lesions. It has to be differentiated from rhino-
scleroma. The latter is, however, a rare affection in this country, and as a
rule is accompanied or even preceded by characteristic changes in the nose
and pharynx. If examined with a probe the latter growth is found to be
hard and cartilaginous, and if a portion of it is removed and sections properly
stained they will show the bacilli of rhinoscleroma.

Prognosis. — In common with other affections of the subglottic region,
this form of chronic laryngitis renders the prognosis much graver than in
the ordinary forms. This is due to two factors ; one is that, being enclosed
in the inextensible shield of the thyroid plate, any increase in size must press
entirely towards the lumen of the air-tube, which is thus apt to become
dangerously narrowed. The second factor is the difficulty of directly
treating diseases situated below the vocal cords.

Treatment. — The plan of treatment recommended in chronic laryngitis
(p. 342) should be followed with perseverance. The thickening and conse-
quent narrowing may be met by the passage of dilators, such as Schroetter's
tubes, or by intubation. When the swellings are cedematous they should
be scarified, and if the dyspnoea becomes dangerous, tracheotomy should be
performed. The tracheotomy may also give an opportunity for more com-
plete treatment of the infraglottic stenosis. With the recent improvements
in the performance of thyrotomy, and the good results obtained, this con-
dition appears to offer a favourable field for laryngo-fissure.

Nodular Laryngitis

Synonyms: Singers' nodules, Teachers' nodules, Chorditis tiiberosa,
Chorditis nodosa, Trachoma of the vocal cords.

Definition. — A form of chronic laryngitis, produced chiefly by faulty
use of the voice, and characterised by thickening of the vocal cords.

Symptoms. — While presenting many of the symptoms of chronic laryn-
gitis, the most characteristic ones of this variety are hoarseness and voice
fatigue. A few days' rest will frequently sufficiently restore the voice for
work, but it soon gets husky towards the end of the day's work, and by the
end of the week the patient is frequently quite hoarse. The rest on Sunday is
sometimes sufficient to enable the patient, if a teacher, to resume work in
the following week, but increasing effort is required in talking, and if care-
is not taken distinct " nodules " are formed. In singers this result is
brought about by a faulty method of voice production, particularly by
attempts to sing in a register beyond the patient's powers, and. by
" squeezing " the voice. Hence they are most commonly met with in tenor
and soprano voices, and are rarely, if ever, encountered in basses and con-
traltos. The method called the coup de glotte has been particularly blamed
as a cause of singers' nodules. Although these small hypertrophies have
generally been called " singers' nodules," they are met with very frequently
in those who only misuse their voices in talking or lecturing. Moure
states that the condition is frequently met with in children who join in
part singing, and are forced to take a register beyond their compass.1

Etiology. — This affection of the vocal cords is induced by the same causes
which are responsible for chronic laryngitis and chronic hypertrophic laryngitis

1 lievue de laryngol. Feb. 8, 1896.

350 LABYNX, ACUTE AND CHBONIC INFLAMMATIONS

(q.v.). It differs from them in etiology in that the use, or rather the misuse, of
the voice is one constant factor. In many cases it appears to be the preponderat-
ing if not the unique cause, but from the greater frequency with which it is met
in young female teachers, it is clear that there are other causes at work, — ansemia,
irregularities of digestion and menstruation, etc.

Pathology. — The hypertrophy may be more marked on one side than on the
other, but it is generally bilateral. It may affect the upper or inner surface of
the cord. It is found to consist of increase of normal stratified epithelium in the
simpler cases ; but in others there is a small-celled infiltration of the submucous
layer — very scanty in this region — while many distinct " nodules " are found under
the microscope to present the characters of oedematous fibromata. In certain
cases, as pointed out by Kanthack,1 the inflammatory process is not limited to the
mucous surface, but entails a certain amount of myositis.

Examination. — Inspection of the larynx always shows — together with more or
less general laryngeal catarrh — hypertrophy of the vocal cords, rarely one-sided.
In some cases this takes the form of a rounded eminence in the centre of the
upper surface of the cord, as if half a small hemp seed had been inserted below
the epithelial surface. But in the majority of cases the site of the nodule is at
the junction of the upper and inner borders, and at one characteristic point, viz.
at the junction of the anterior and middle thirds. Sometimes before any nodule
is distinctly present, and when the patient is complaining simply of voice fatigue
and occasional hoarseness, the only change apparent on inspection is a slight
churning up of mucus into a little froth at 'this situation when the cords are
approximated. Later on the cords lose their normally white surface and become
dull, slightly translucent, and injected at this point. Finally a nodule appears,
generally on both sides, although it is frequently more prominent on one side
than on the other. This nodule may vary from the size of a turnip seed up to
that of a small pea. Its surface is smooth and it is generally semi-translucent,
although a few vessels may be seen along its broad attached border. On
attempted phonation the nodules of course prevent complete coaptation of the
cords, and as a space is left in the glottis there is phonative waste. This gives
the toneless and hollow harsh sound to the voice. Although these nodules are
generally sessile and attached by a broad base, in certain instances they are more
mobile, and by an increased effort of phonation the patient will be able to produce
a clearer note. With the laryngoscope it will be seen that this is effected by the
nodules being forced up on to the upper surface of the cords, so that the inner
margins are able to approximate.

These nodules, being dependent on the conditions already mentioned, are of
course always accompanied by a certain degree of general laryngeal catarrh.
Interfering as they do with the free movement of the cords, the tensors of the
latter necessarily become impaired. This is not only from want of use, but, as
Kanthack pointed out,2 because the condition is an inflammatory one, and affects
the muscles as well as the mucous membrane.

Increasing hoarseness and sense of fatigue compel the patient to rest the voice
and this always secures a certain amount of relief, but the symptoms and the local
conditions generally quickly recur as soon as the patient returns to his injurious
surroundings and the over-use or misuse of the voice.

Treatment. — The early stages of this affection should be treated on the
lines laid down in the sections on chronic and hypertrophic laryngitis.
Before resuming professional use of the voice, it is desirable that faulty
methods of using it should be corrected.

It is seldom that caustics should be used for this condition, and I
cannot agree with Botey that it is ever desirable to introduce the point of
a galvano-cautery into the larynx, considering how dangerous such a pro-
ceeding may be even in the hands of the most skilful, owing to sudden
movement on the part of the patient and the amount of reaction always
set up by a cautery. If the circumstances of the patient make prolonged
treatment impossible, or the nodules are well marked, they can be removed
with intra-laryngeal forceps. In the majority of cases, and in patients
who can afford the time, the treatment recommended for chronic laryngitis

1 Kanthack, Trans. Laryngol. Soc. London, 1897.
- Loc. cit.

LAKYNX, ACUTE AND CHKONIC INFLAMMATIONS 351

will generally be successful, especially when combined with strict rest of
the voice. In some cases the silence should be absolute, although improve-
ment is sometimes quicker if the " humming " exercises recommended by
Holbrook Curtis1 are carried out.

Laryngitis Sicca

Synonyms : Chronic Atrophic Laryngitis, Ozamatous Laryngitis,
Ozazna of the Larynx.

Definition. — A chronic inflammation of the mucous membrane of the
larynx, resulting in atrophy, and generally associated with the formation
of crusts.

Etiology. — It is questionable if this ever originates primarily in the
larynx. When symptoms simulating it are found limited to the larynx
they are generally the consequence of mouth-breathing or of syphilis.

The disease is nearly always the result of purulent processes in the nose
— suppuration in the accessory sinuses, ozaena, syphilis, neglected adenoids,
etc. It is originated in the larynx either by the pus trickling into the
larynx, or by the inhalation of pyogenic organisms from the nose, or as a
result of the mouth-breathing induced. It is more common in females.

Symptoms. — Interference with the voice is the leading symptom in this
disease. It is worse in the morning, or after working in a dusty atmosphere.
When the patient has succeeded in expelling some of the crusts adhering to
the mucous surface the voice is quickly restored, although still hoarse. This
expulsion of the dried secretion entails a great deal of painful coughing and
hawking, and is sometimes accompanied or followed by a little haemoptysis,
due to the abrasion consequent on the separation of the sticky crusts. The
expectorated crusts have sometimes a very foul ozaenatous odour. The
mucus begins to dry again at once, and as the crusts form the patient
becomes gradually more or less aphonic and experiences considerable pain
in speaking.

Examination shows the presence of chronic laryngitis, and in addition
the atrophy and crusts which are characteristic of the disease. The latter
may be found almost anywhere, but are perhaps most common in the inter-
arytenoid region, the posterior ends of the cords, and the ventricular bands.
They can frequently be seen in the trachea. The mucous membrane is pale
and wasted, and when the crusts are removed the surface underneath them
is seen to be abraded. The tension of the cords has generally been con-
siderably damaged.

In the majority of cases purulent processes can be traced up to the
post-nasal space and the nose, and the etiological conditions mentioned will
be found causing other symptoms.

Pathology. — The process begins from the mucous surface, which is first
infected, and then abraded. Many of the mucous glands are destroyed. The
underlying tissue is replaced by connective tissue. There is anaemia from
the constant presence of septic material, and atrophy from want of use of
the muscles.

Prognosis. — Chronic atrophic laryngitis is a chronic disease and seldom
shows any spontaneous tendency to cure. In those cases where it is found
to be dependent on a focus of suppuration in the nasal cavities which can
be removed, there is good hope of effecting a practical cure, although
some amount of chronic laryngitis might still be left as a legacy of the
long-standing process.

1 Voice- Building and Tone-Placing, New York, 1898.

352 LAEYNX, ACUTE AND CHEONIC INFLAMMATIONS

Tkeatment. — From what has already been said it will readily be
gathered that in the treatment search must first be made for an etiological
condition in the pharynx and nose, and treatment directed accordingly.
The possibility of a syphilitic diathesis, acquired or congenital, should not
be lost sight of, and even when there is nothing to point to specific disease
as the primary cause relief is frequently obtained from the stimulation of
the atrophied laryngeal glands by the administration of small doses of
iodide of potassium.

A healthier condition of mucous membrane may be promoted by paint-
ing with some form of Mandl's solution.1 The use of the trochisci acidi
carbolici of the Throat Hospital Pharmacopceia is cleansing and comforting.

The larynx should be sprayed or syringed out frequently with an
alkaline solution, and when freed of crusts it should be lubricated with a
spray of paroleine containing menthol or other antiseptics. If the mucous
surface is abraded it should be treated with nitrate of silver or similar caustics
as directed in the sections on the other forms of chronic laryngitis. Dust,
alcohol, and tobacco should particularly be avoided. A visit to the alkaline
or sulphur spas of Ems, Mont Dore, Challes, Marlioz, Aix, or Harrogate will
generally be found beneficial.

Acute Laryngitis in Children

There are certain anatomical peculiarities connected with the larynx
in children which demand some special consideration of laryngitis in young
subjects.

In childhood the larynx is not only absolutely smaller than in the
adult, but it is relatively small in proportion to the development in other
regions. The cartilages which compose its framework are much softer than
in the adult, and therefore yield more readily to either direct or negative
pressure. The mucous membrane is less closely adherent to the subjacent
tissues, particularly in the ary-epiglottic folds and subglottic region, and as
a consequence effusion, and consequent stenosis, takes place more readily.

The lymphatic supply of the mucous membrane is richer in children
than in adults, and hence acute laryngitis is more apt to be attended with
submucous infiltration.

In consequence of these anatomical peculiarities inflammation of the
laryngeal mucous membrane produces acute symptoms much more quickly
than in the adult, and the symptoms of dyspnoea and cyanosis are apt to
appear early. Besides, not only is the nervous system of the child generally
more unstable, but it appears to be particularly sensitive when the larynx is
attacked.

In forming a prognosis it should be borne in mind that there is a possi-
bility of risk from spasm of the glottis. Acute laryngitis is always a serious
affection in childhood, and the younger the patient the greater the danger.

The symptoms sometimes give rise to what has been called false croup.
The child may appear quite well through the day or be affected only with
a slight cough. During the night dyspnoea may develop rapidly and
alarming symptoms of spasm may set in. In most cases these are con-
nected with naso-pharyngeal catarrh, and the symptoms are partly those
of laryngismus stridulus.

The treatment suitable will be found under the headings of "Acute
Laryngitis " (p. 338) and " Laryngismus Stridulus " (p. 410). In children
it has been found that emetics are more useful than in adults, and the
1 ^ I°di Pur. gr. v., Pot. Iod. gr. xv., 01. Menth. Pip. ttiv., Paroleine gj.

LARYNX, ACUTE AND CHRONIC INFLAMMATIONS 353

administration of a teaspoonful of vinuni ipecacuanha} will often remove a
quantity of obstructing secretion. Hot applications over the larynx are
particularly useful in children. Finally, it must be remembered that with
them life is more readily threatened by acute laryngitis, so that the prac-
titioner should be prepared for intubation or tracheotomy.

Injuries to the Larynx

Etiology. — Fractures of the laryngeal cartilages are nearly always the
result of direct violence. They are not of common occurrence, and this is
probably due to the elasticity of the cartilages and the mobility of the
larynx as a whole. Concussion alone does not appear to be sufficient to
fracture the thyroid or cricoid cartilages, unless the violence is directly
anterior and the vertebral column is immovable. Hence these accidents are
nearly always the result of direct violence, and most commonly occur when
the patient is lying on his back. They are therefore apt to be met with
when people fall in the streets and carriage-wheels pass over the front of the
neck. A case has been recorded (Mackenzie) x in an acrobat who was in the
habit of lying flat on his back, while another gymnast jumped on his neck.
In garrotting the larynx is often fractured, not by pressure against the
vertebral column, but by lateral compression of the wings of the thyroid
cartilage. It occurs in the same manner in hanging. In almost all cases
these accidents have originated from some form of direct violence. The
only exceptions are three or four cases of fractured hyoid bone in which
the injury has been due to muscular action.

Ossification of the cartilages will render the cartilage more brittle and
liable to break under the influence of violence.

Symptoms. — The symptoms produced by these, injuries are local pain
and tenderness, swelling of the surrounding parts, and more or less inter-
ference with respiration, articulation, mastication, and deglutition. On
manipulation there will be found displacement, mobility of the fragments,
and crepitus. It is important, in connection with this, to bear in mind that
even when the normal larynx is moved from side to side over the cervical
spine a sort of crepitus is often felt. Overriding of the fractured edges
will give rise to a perceptible deformity ; but, needless to say, in many cases
the recognition of these signs will be impossible.

Laryngoscopic examination may reveal swelling, congestion, or haemor-
rhage into the larynx, and would not only prove useful in diagnosis, but
might also be of assistance in giving warning as to the amount of inter-
ference with respiration, and so indicate the necessity for an early
tracheotomy.

Emphysema of the neck is likely to supervene, and the air will not only
distend the cellular tissue of the neck, but may extend to the thorax, back,
arms, and abdomen.

Pkognosis. — Fractures of the laryngeal cartilages are attended with
fatal consequences in a large proportion of recorded cases. The recorded
cases of fracture of the larynx show a mortality of from 76 to 80 per cent.
Fracture of the thyroid cartilage is a more serious accident than fracture of
the hyoid bone, while fracture of the cricoid cartilage appears to have been
fatal in every recorded case. Statistics also show that the prognosis is very
much more grave when two of these cartilages are injured at the same time ;
and the same fact has been observed when there has been accompanying
fracture of the lower jaw.

1 The Throat and Nose, vol. i. 1880, p. 402.
VOL. VI 23

354 LAEYNX, ACUTE AND CHEONIC INFLAMMATIONS

Still, it is somewhat doubtful if these injuries are always of such a
serious nature as statistics would tend to show. In many cases the fracture
may pass unrecognised during the lifetime of the patient. Arbuthnot
Lane,1 in 1885, reported that he had found evidence of old fractures of the
hyoid bone or laryngeal cartilages in nine out of one hundred bodies which
he had examined in the dissecting room ; and, indeed, in one instance, there
was even a healed fracture of the cricoid cartilage.

Besides, among the cases included in the tables of various writers, there
are many in which death has been caused by suicide or by homicide, and
thus the mortality rate is considerably increased.

Treatment. — The chief danger lies in the interference with respiration.
If this be met by an early performance of tracheotomy, there is no reason
why a much larger proportion of patients should not recover than has
hitherto been the case.

Some writers recommend that a tracheotomy should be done in all cases,
and that even where the diagnosis is not quite certain the operation should
nevertheless be carried out. It is certainly well not to allow the onset of
suffocation to be the indication for performing tracheotomy. A fatal attack
of dyspnoea may occur suddenly in any case, so that no patient should be
left beyond the reach of an immediate tracheotomy.

It has been suggested that O'Dwyer's method of intubation (vide vol. v.
p. 454) might find a suitable field of usefulness in these cases ; but when
the cartilages are much crushed it would probably be safer to lay open the
whole larynx, after a preliminary tracheotomy, and endeavour to replace
the fragments in their proper position before inserting an intubation tube
to act as an internal splint.

Dislocations of the Larynx

Intra-laryngeal dislocations are very rare. One or both of the arytenoid
cartilages are sometimes dislocated downwards and forwards, or one may be
displaced inwards.

The symptoms are seldom prominent, and the condition is frequently
only encountered accidentally when making a laryngoscopic examination.

Foreign Bodies in the Larynx

Various foreign bodies not infrequently obtain entry to the larynx, and
their presence there is always fraught with great danger and sometimes with
alarming symptoms. In a few cases, curiously enough, they may, for a time
at least, give rise to very little distress.

It is difficult to give a complete study of the question of foreign bodies
with reference to the larynx only, as they not infrequently pass from the
larynx to the trachea, or lower down ; and, on the other hand, foreign
bodies which at first are lodged in the lower air -passages may become
impacted afterwards in the larynx. The occurrence of foreign bodies in the
upper food-passages has also to be frequently considered at the same time.
Eeferences to these regions will therefore complete any omissions in the
present section.

Etiology. — Large foreign bodies generally consist of imperfectly masticated
boluses of food which become fixed in the laryngo-pharynx. Sometimes they consist
of some substance — food or other material — swallowed for a wager. Smaller bodies
may be particles of food slipping unexpectedly out of the mouth, swallowed hastily,

1 Path. Soc. Trans, vol. xxvi. 1885, pp. 82-85.

LAEYNX, ACUTE AND CHKONIC INFLAMMATIONS 355

or unexpectedly met with, as when portions of hone are drunk with soup. Vomited
matter sometimes finds its way into the larynx, and this is most likely to occur
during or after general anaesthesia. Food is also apt to " go the wrong way "
when the sensation of the pharynx and larynx is blunted, as in alcoholic intoxica-
tion, in the insane, and in certain neuroses of these regions. In diphtheritic
paralysis such articles of diet as tea, milk, and bread and butter have been
inspired into the larynx.1 The same accident is apt to occur with epileptics, and
from accidents, as when a man is thrown from horseback when smoking a pipe.

The blood effused in haemoptysis may act as a foreign body, especially if the
patient faints and is placed on his back instead of on his side.2

Foreign bodies are sometimes pushed through the nose and drop into the
larynx. The accident may occur in surgical procedures, as when adenoid growths
are removed in such a manner as to allow of their dropping into it. The use of
throat brushes and instruments, with easily detachable extremities, is also fraught
with this danger.

One of the most usual methods by which a foreign body enters the larynx is
the following : — Some substance is introduced temporarily into the mouth, and,
owing to the patient's attention being attracted elsewhere, is partly forgotten.
Some unexpected cause initiates the deep inspiration which precedes a start, cry,
laugh, or sneeze, and the foreign substance is drawn directly into the larynx.

The list of substances, in addition to articles of food, which may be met with,
is too varied to attempt to make it complete, but the following have been found
in the larynx : — coins, pins, needles, buttons, various seeds (beans, peas, corn), toys,
pieces of wood, portions of pipe-stalks and cigar-holders, and leeches. Bronchial
glands have ulcerated through into the trachea, and been coughed up into the
larynx.

When the substance is large it generally obstructs the aditus ad laryngem.
Smaller bodies may rest on the ventricular bands, or get wedged between the vocal
cords, sometimes with one edge in a ventricle of Morgagni. On deep inspiration,
or injudicious attempts at removal, they may pass downwards into the trachea.

Symptoms. — When a large bolus of food or other foreign body com-
pletely blocks the laryngo-pharynx, death by asphyxia rapidly occurs unless
relief is obtained. A barman was in the habit of showing how he could
place a billiard ball in his mouth and close his lips over it. While perform-
ing the trick he was of course quite aphonic. On one occasion the billiard
ball slipped into the lower pharynx, and his frantic signs for relief were
regarded by the amused onlookers as part of his jest. He died, and the
ball was found entirely blocking the upper larynx.

When the substance is small enough to enter the larynx it produces
dyspnoea and inspiratory stridor in proportion to its size and its situation
over the glottis. If it gets between the cords it is apt to become grasped
spasmodically, producing great anxiety. The trauma produced may lead to
acute oedematous laryngitis (q.v.).

The cough induced is frequently extremely insistent, and will some-
times continue for some time after the foreign body is expelled.

Examination. — In all cases when the symptoms are not very urgent, the
throat should be carefully examined before making any attempt at removal. A
laryngeal inspection can generally be obtained by the use of cocaine and the
infusion of a little confidence into the patient. The size, nature, and position of
the body can thus be exactly observed. Sometimes, owing either to the thick
strings of mucus which may extend from one side of the throat to the other, or
to the translucent character of the foreign body (as fish-bones or glass beads), it
remains invisible. In such cases the careful use of a probe will often assist in the
examination, and it is only when these efforts at locating it have proved fruitless
that it is justifiable to attempt to use the forefinger to detect the body. This
latter proceeding, however, is frequently required in young children, in whom a
laryngoscopic examination is not always possible.

If the presence of the foreign body in the upper air or food passages still

1 Hale White, Trans. Clin. Soc. Feb. 23, 1894.
2 Bowles, Brit. Med. Jour. July 23, 1898.

356 LABYNX, ACUTE AND CHEONIC INFLAMMATIONS

remains doubtful, the power of swallowing should be tested and the chest carefully
examined.

In many cases, particularly where metallic substances have been inspired into
the larynx, the use of the Ilontgen rays has proved of great service both in
settling the presence of a foreign body and in determining its exact position.

When, in spite of careful examination, the situation of the foreign body cannot
be diagnosed, but the suspicious symptoms still suggest its presence, the patient
should be kept under observation, when, either by the development of fresh
symptoms or by the shifting of the substance, the diagnosis can be completed.

In many cases, probably the majority of those which present themselves, no
trace of the offending substance can be found. The patient can then be reassured
and the irritation remaining can be treated. In certain cases, in spite of the fact
that the discomfort is referred by the sufferer to the larynx, the irritant will be
found outside the larynx, in the sinus pyriformis, the base of the tongue, the
tonsils, or elsewhere.

Treatment. — Once the presence of a foreign body in the larynx has
been definitely detected, it ought never to be left there, even if it is causing
no serious symptoms. When the foreign body is even suspected, no
attempt at treatment should be made until the implements for a speedy
tracheotomy are all at hand. Under the effect of cocaine, and with good
illumination, intra-laryngeal removal should then be attempted by one of
the various forms of intra-laryngeal forceps. This is much more scien-
tific than the frequently recommended plans of inversion with slapping
the back. The latter may be had recourse to when attempts at intra-
laryngeal extraction have failed, always provided that a tracheotomy can be
performed on the spot if the foreign body should happen to shift from a
harmless to a dangerous position, or suddenly produce threatening spasm.

When dyspnoea is marked, or other methods have failed, or the patient
has to be left out of call of prompt relief if required, then the trachea
should be opened. When in doubt it is much safer to do the operation
than to leave the patient with a foreign body in the larynx. The substance
can be sought for from the tracheotomy wound, and may either be extracted
through it or pushed up into the mouth and so removed. If impacted in
the larynx it can be "removed by a subsequent thyrotomy.

Laryngeal Hemorrhage

This includes two separate pathological conditions.

(a) Submucous hemorrhage of the vocal cords is a rare affection and occurs
chiefly in singers. It takes place suddenly, and the patient complains of hoarse-
ness. Probably it is predisposed to by slight local catarrh. The coincidence of
menstruation appears to be a predisposing factor. It has also followed sneezing,
coughing, and attempts at topical applications.

Examination shows an effusion of blood below the mucous membrane, generally
limited to one cord. Sometimes it appears as a small, round, dark-red cystic
tumour (for treatment vide " Chronic Laryngitis ").

(6) Superficial Laryngeal Haemorrhage. — This is alarming, and often difficult to
diagnose. It may be due to (a) acute inflammation and various forms of
ulceration, (b) changes in the blood and blood-vessels, and (c) trauma following
strangulation or slighter causes.

In the second group are angioma of the larynx, local varicose veins, and small
varicose aneurysms, also cirrhosis of the liver, heart disease, albuminuria, diabetes,
phthisis, malignant fevers, haemophilia, purpura, leukaemia, anaemia, etc.

Diagnosis is made by the laryngoscope. Special attention must be paid to the
nose, the region at the base of the tongue, and the trachea. In all cases where
the bleeding point is not discoverable, examine for early indications of pulmonary
tuberculosis (q-v.).

Treatment. — Local and general rest, and that generally indicated in haemor-
rhage. Abstention from use of the voice, sucking of ice, and the administration
of morphia will generally be sufficient. The application of astringents is of
doubtful value and apt to irritate.

LARYNX, ACUTE AND CHRONIC INFLAMMATIONS 357

Congenital Glottic Stenosis

Synonyms : Webs of the larynx ; Pseudo -membranous stenosis ; Diaphragms
of the larynx ; Congenital laryngeal stenosis.

The occurrence of a congenital diaphragm in the larynx is a rare
condition. Semon has recently published a case which, from his
researches, appears to be only the sixteenth placed on record. In 1893
Paul Bruns published an essay enumerating twelve cases of this class
which he had. found in literature, and adding one of his own. Single
observations have been recorded by Chiari and Lacoarret.

Etiology.— It has sometimes been doubted if these webs are ever really
congenital, and it is of course rather difficult to establish the point, as it is
only when a child begins to acquire the faculty of speech that any defects
of phonation become strikingly obvious. This matter, however, appears to
have been settled by Seifert, who found that in a family of six persons no
less than four showed more or less marked evidence of laryngeal webs. From a
careful consideration of the history of these cases it was fairly clear that the
affection is not only apt to be hereditary, but is also undoubtedly congenital.

Symptoms. — If the laryngeal diaphragm is well marked the first
symptom which it may cause will be stridor, chiefly inspiratory, and this
will be noticeable at or soon after birth, and will be associated with other
symptoms similar to those described under " Congenital Laryngeal Stridor "
(p. 407). But the cry will be more or less hoarse, and when speech
develops the voice will be harsh and weak. Dyspnoea on exertion, and
inspiratory stridor, as well as the interference with voice, will all be pro-
portionate to the size and position of the web.

Examination. — The laryngoscope reveals the cause of the above
symptoms. Tha diaphragm is nearly always limited to the anterior part
of the glottic space. The rest of the larynx is usually normal. The web is
seen to stretch across the anterior commissure from one vocal cord to the
other. It is symmetrical, somewhat translucent and membranous-looking,
and in some instances slightly pink. It is triangular in shape, with the
apex at the junction of the cords. The base or free border is not quite
rectilinear, but is generally curved, and the restricted glottic space lies
between this border and the inter-arytenoid space. This edge, as a rule, is
white, and appears to be thicker than the main part of the membrane.
The membrane increases in thickness again as it approaches the anterior
commissure. On phonation it is seen that the cords move freely, but their
complete approximation anteriorly is prevented by the membrane which
becomes folded between them.

Slighter indications of such a membrane are frequently met with. In
many cases it it foreshadowed only by a rounding of the ordinary acute
angle at the anterior junction of the vocal cords. In other cases a small
fold of membrane is seen in the subglottic region below the anterior
commissure entirely unconnected with the cords, and apparently causing no
symptoms. The thickness of the web increases from behind forwards.

In only one case — that of Chiari's— did the web occupy the posterior
region of the larynx.

Pathology. — As to the pathological causation of these webs there is
nothing in their appearance to suggest an inflammatory or pathological
origin, and the source of the malformation has not yet been explained.
There is nothing in the development of the larynx to throw light on the
subject, but Eoth has shown that the upper part of the air-tube in its
first development is glued together, the epithelial gluing matter being

358 LAEYNX, ACUTE AND CHEONIC INFLAMMATIONS

formed in part from elements of the outer terminal layer (epiblast), and
in part from the elements of the intestinal gland layer (hypoblast). Bruns
finds in these observations a clue to the explanation of the occurrence of
these laryngeal webs. The cause of their formation would seem to be
traceable to the agglutination of the original formation being only incom-
pletely loosened and persisting in part.

Treatment. — The treatment will depend entirely on the amount of
interference with respiration. In the slighter forms, and particularly when
there is no dyspncea or stridor, and the voice is not greatly interfered with,
the wisest plan is to leave the web strictly alone, warning the patient of
his condition and of the greater precautions he should take in the event
of laryngitis or other inflammation of the respiratory tract. When there
is more or less complete aphonia, when there is stridor or dyspnoea, relief
must be obtained by surgical measures. The most complete and radical
method of removing the web would, at first sight, appear to be by splitting
the thyroid cartilage (laryngo- fissure or thyrotomy), but it has been found
that in these cases there is marked tendency for adhesion to take place
after this operation between the raw anterior extremities of the cords, so
that intra-laryngeal treatment is required for some time afterwards to
prevent an even worse form of stenosis. Before inaugurating treatment
for the removal of the obstruction by intra-laryngeal methods it is well to
bear in mind the fact that in several instances these webs have been found
to be extremely tough, so much so that in Seifert's case x the intra-laryngeal
knife actually broke in the tough issue, and Semon found it quite impossible
to make an incision into the web. He was successful by first using the
galvano-cautery to divide the web up into portions, which were later on
removed by intra-laryngeal forceps. Other cases have required careful
dilatation by Schroetter's or other laryngeal dilators, and such cases appear
to offer a useful field for O'Dwyer's method of intubation. Some cases
have required tracheotomy, and then the stenosed portion has been
attacked from below. For further methods of treatment vide p. 405.

Pachydermia Laryngis

Definition. — This term has been applied to a form of hypertrophic
laryngitis which has received considerable attention from the fact that
its pathology has been fully investigated by Virchow. Possibly this has
secured for the affection more attention than it warrants, for, as will be
seen later on, it is but one clinical form of the hypertrophic variety of
chronic laryngitis. In Virchow's original paper 2 he described two forms
of pachydermia. One, in which the hypertrophy was limited to the
anterior part of the vocal cords, he called pachydermia verrucosa or the
warty form. To the second form he applied the term diffuse pachydermia.
The former need not be considered ; it hardly ever established itself as
a pathological entity, and with the progress of laryngology it has dis-
appeared. With regard to Virchow's second group, although its claim to
a separate class may be doubted, it is still convenient to retain it as a form
of hypertrophic laryngitis. It is a chronic affection characterised by more
or less symmetrical thickenings over the posterior ends of the vocal cords
and the neighbouring parts of the inter-arytenoid space.

Symptoms. — As the disease is more particularly limited to the posterior
part of the larynx and so does not interfere with the approximation of the
greater portion of the cords, it causes a less degree of hoarseness in the

1 Berlin. Tclin. Wocli. 1886, No. 10. 2 Ibid. No. 32, 1887.

LAEYNX, ACUTE AND CHEONIC INFLAMMATIONS 359

earlier stages than a smaller growth would produce if situated more
anteriorly. Otherwise the symptoms are much the same as those of chronic
laryngitis. In marked cases there is dyspnoea on exertion.

Etiology. — The disease is more common in men than in women, and usually
occurs in middle life, from thirty to sixty years of age. It is frequently attribut-
able to the same causes as catarrhal chronic laryngitis, and more particularly to
excess in alcohol and in smoking. Still, cases of it do occur in which it is difficult
to ascribe it to any of the ordinary causes of laryngitis, and it does not appear to
be particularly attributable to over-use of the voice.

Examination.— The laryngoscope reveals an affection of the posterior ends of
both vocal cords. Situated over the vocal process on one side is an even elongated,
pink or gray thickening, with a slight central depression facing towards the
opposite side. On the opposite vocal process is another hypertrophy, generally
somewhat smaller, and either with a blunt summit or with a smaller central
depression, which, on phonation, is seen to fit into the cup-like depression on
the opposite side. It was formerly thought that the depression on one side was
caused by the pressure of the hypertrophy of the opposite vocal process. It is
more likely that a close examination would reveal a depression on both sides,
although more marked on the side with the larger hypertrophy, and that in both
cases the dimpling in the centre is due to the closer attachment of the mucous
membrane at that point to the subjacent cartilage. The hypertrophies are free
from inflammation or ulceration, they are generally bathed in sticky mucus, which
may stretch across in threads from one side to the other after the thickenings are
pressed together on phonation, and then gape apart in respiration.

Occasionally the hypertrophy is limited to one side, in which case the opposite
processus vocalis may be indented from pressure.

In some cases the rest of the larynx is normal, while in others there are the
usual symptoms of chronic laryngitis. The movements of the cords are frequently
somewhat impaired.

Pathology. — The hypertrophies are found to be formed of a white or gray-
white thickening, which can be stripped off in layers and is found to consist of
epithelium thickened and undergoing epidermoidal change. The subepithelial
connective tissue is also thickened and sends upwards papilliform processes into
the epithelial layer. All degrees may be met with, from a slight elevation due to
some heaped-up epithelial cells, to an outgrowth of some size. Inflammatory
changes may be observed in the thickened sub-epithelial connective tissue, but
there is always a distinct line of demarcation between epithelium and connective
tissue.

Diagnosis. — In some cases the movement of one of the cords may be
affected and the suspicion of malignant disease may be aroused. From
epithelioma, and from other affections-, pachydermia can be distinguished
by the facts that it occurs in middle-aged males ; by the history ;
by the slow growth ; by the discovery of a similar condition — even if
not so marked — on the opposite side ; and by the crateriform depression.
In doubtful cases the removal of a portion of the growth for microscopic
examination may be advisable, although only positive evidence of cancer
would be of any value (see also p. 385).

The diagnosis has sometimes to be made between simple pachydermia
and that due to syphilis and tubercle.

Prognosis. — The prognosis is favourable as regards life, and continued
— if impaired — use of the voice can generally be promised.

The disease is a very chronic one, and not very amenable to treatment.
There is no clinical evidence that it is apt to assume a malignant character.

Treatment. — The reader is referred to the sections on the treatment of
chronic laryngitis — catarrhal and hypertrophic. The internal adminis-
tration of iodide of potassium is generally recommended. Sprays or laryn-
geal washes of salt water are frequently of use. Painting with nitrate of
silver in solutions of increasing strengths here finds its most suitable field
of application. Iodine has failed in the hands of Stoerk and Gottstein.

360 LABYNX, CHEONIC INFECTIVE DISEASES

Sulphur spas may be tried, and painting with lactic acid or salicylic acid in
alcohol may be tried. Electrolysis is recommended by Chiari.1 Attempts
to extirpate the growth are liable to set up perichondritis.

Blennorrhea

Under this title a particular condition has been described by Stoerk.2
It is an affection which is extremely rare, if not unknown, in this country,
but appears to be not infrequently met with in Poland, Wallachia, and
neighbouring parts of Central Europe.

It is said to assume a form of chronic laryngitis, chiefly subglottic, with
free secretion, and is sometimes followed by stenosis or adhesion between
the anterior parts of the vocal cords. It may be accompanied by an
analogous condition in the nose.

It is possible that the condition — references to which are seldom met
with in literature — has been confused with chronic subglottic laryngitis
and with rhinoscleroma (see also p. 367).

Larynx, Chronic Infective Diseases

fNGEAL Phthisis .

. 360

Lupus of the Larynx

. 364

Manner of Infection in .

. 360

Syphilis of the Larynx —

Symptoms .

. 361

Clinical Features .

. 365

Diagnosis

. 362

Treatment .

. 367

Prognosis

. 363

Scleroma

. 367

Treatment .

. 363

Leprosy ....

. 368

Laryngeal Phthisis

Laryngeal phthisis is commonly secondary to a similar condition of the
lungs. It is still an open question how the infection of the windpipe
occurs. According to some authorities it results from bacilli either entering
the glands by way of the ducts or making their way through injured
epithelium, while others maintain that these organisms may pass through
healthy cells without leaving any trace of their passage. A third group of
observers affirm that infection of the larynx usually results from the
circulation, either vascular or lymphatic.

While in most cases laryngeal phthisis is associated with and dependent
upon pulmonary disease, various authors (Demme, E. Erankel, and others)
have published undoubtedly authentic instances of primary tuberculosis of
the larynx. The first morbid appearances result from tubercular infiltration,
which involves both the mucous and the submucous layers, while the glands
are usually also affected. Very rarely, as described by Schech and Heinze,
tubercular deposits may occur in the laryngeal muscles.

In most if not all cases infiltration is followed sooner or later by
ulceration. The resulting ulcers may be superficial or deep, and in the
former case are often multiple. In certain instances laryngeal tuberculosis
shows itself by the presence of tumours. Sometimes a circumscribed sessile
neoplasm occurs in the inter-arytenoid space. Such growths are composed,
according to Gouguenheim and Glover, of epithelium and connective tissue,
with perhaps a layer of tubercular granulations in process of evolution, but
these authors failed to detect bacilli. Again, more definitely tubercular
growths may be present. These may be single or multiple, are usually pale

1 Archivfiir Laryngol. Bd. ii. 1, 1894.
2 Klinik der Krankheiten des Kehlkopfes, Halfte 1, Stuttgart, 1876.

LAKYNX, CHRONIC INFECTIVE DISEASES 361

in colour, and vary in size from a pea to a hazel-nut. Finally, Avellis has
shown that a proportion of those growths which have been hitherto regarded
as papillomata and fibromata are in reality tuberculous.

Like all laryngeal affections phthisis is more common in males than
in females, while the period of life which statistics have shown to be most
liable to attack is between the ages of twenty and forty.

So far I have referred merely to the lesions which occur after infection
has taken place, but there can be no doubt that there are certain changes
in the larynx which, when they exist, ought to warn the practitioner to
make a careful examination of the lungs. It is no uncommon thing to find
at an extremely early stage of pulmonary phthisis various signs and
symptoms which lead the patient to consult a throat specialist rather than
a physician. Thus the larynx may be the seat of abnormal sensations, and
examination will then often reveal very marked ansemia of the mucosa,
which may perhaps flush during examination. Again, there may be paresis
of adduction, often also associated with pallor. These conditions cannot as
yet be said' to have any recognised pathology. On the border-land between
these on the one hand, and conditions obviously due to infection on the
other, we must consider the very obstinate laryngeal catarrh which is some-
times a precursor of tubercular infection of the part, if indeed it be not in
certain cases an early manifestation of such infection.

Symptoms. — In considering the semeiology of laryngeal phthisis it has
seemed to me better to give the symptoms of each clinical form which the
practitioner is likely to meet with, as they vary according to the seat of the
infiltration or ulceration.

Perhaps, on the whole, interference with the voice is the commonest
symptom. This varies in degree from slight hoarseness to complete
aphonia. In certain cases, too, vocal effort is accompanied by pain. Various
localisations of laryngeal phthisis may produce the above symptoms.

As before said, there is a form of laryngeal catarrh which occurs in
phthisical persons, and which may eventually be followed by infiltration and
breaking down of tissue. In many instances there are no objective points by
which it can be distinguished from the non-tubercular form. In other cases
suspicion may be aroused by a tendency to localisation. Thus the occurrence
of redness confined to one vocal cord is suspicious. Again, ordinary catarrh is
not usually accompanied by any marked thickening, which if present in a
phthisical subject will usually be found to be tubercular. At a later stage
of the disease one or both cords may become distinctly infiltrated. The
infiltration is usually of a red colour, and may result in uniform enlargement ;
on the other hand, it may be more or less circumscribed. Occasionally
infiltration may occur at the anterior commissure or just below it, but this
is a somewhat rare appearance. Much more common is a distinct flat
tumour occupying the inter-arytenoid region. This is sessile, usually of a
red colour, and may have a relatively well-defined regular surface, or may
be uneven and papillary. These inter-arytenoid tumours may precede all
other manifestations of phthisis, and much importance was attached to
them by Stoerk, who considered them infallible indications of a tubercular
taint.

After a time infiltrations such as have been described tend to break
down, and ulceration results. In the vocal cords various appearances may
be produced. Sometimes small losses of substance occur at the edges,
and these are separated from each other by red infiltrated tissue, which may
appear like granulations. Occasionally the free edge becomes distinctly
serrated, while not uncommonly a relatively deep excavation occurs in the

362 LAEYNX, CHKONIC INFECTIVE DISEASES

neighbourhood of the vocal process. A peculiar appearance is sometimes
produced by an ulcer extending along the cord. In such cases this part
looks as if doubled or cleft longitudinally.

"When ulceration occurs on the posterior laryngeal wall the surface of the
ulcer is usually not well seen, but the raised upper margin, often with a
ragged outline, can be distinguished. Ulcers in this situation may interfere
little with the voice, but sometimes give rise to most distressing cough.

Infiltration of the false cords may occur without any prominent
symptoms, unless the parts be sufficiently enlarged to interfere with the
movements of the vocal cords. When breaking down occurs, numerous
small and often superficial ulcers may result, or several softened areas may
coalesce, and lead to a deeper loss of substance.

Pain, either spontaneous or associated with phonation and deglutition,
with or without huskiness, may be present when the epiglottis and ary-
epiglottic folds become involved.

Infiltration of the epiglottis usually shows itself by very marked and
more or less uniform thickening of the part, which may be red in colour,
but which is frequently of a bluish gray tint. Associated with the enlarge-
ment there is usually interference with mobility. Ulcers, when they occur
in this situation, are usually multiple and superficial, although at times
deeper destruction of tissue may occur.

A very common lesion in phthisis is infiltration of the ary-epiglottic
folds. These appear much enlarged, and in the region of the arytenoid
cartilages present pale pyriform cedematous - looking tumours. After a
time small scattered ulcers may appear, but it is not common to see deep
losses of substance in this situation.

It will be obvious from what has just been said, that hoarseness and pain
are the two prominent symptoms produced by laryngeal phthisis. The
former is liable to occur when the vocal cords are attacked, and may also be
sometimes present when the ventricular bands are much enlarged.

When the epiglottis and ary-epiglottic folds are the chief seats of disease,
pain becomes a frequent symptom. In slight cases this is only noticed on
speaking or swallowing, but in aggravated instances deglutition may become
well-nigh impossible. Not infrequently it is complained of as shooting up
to the ear. When more or less fixation of the arytenoid cartilages has
resulted, marked huskiness and even aphonia may be present.

As the disease advances, the whole larynx is liable to become attacked,
and at this stage the secretion from the various ulcers may be so great as to
cover the parts and prevent any detailed diagnosis as to their condition. In
the later stages, too, perichondritis and diffuse general swelling may lead to
interference with respiration. In a previous paragraph tubercular tumours
have been referred to. Their presence can be diagnosed by means of the
laryngoscope, but it is questionable whether we possess any data by which
we can distinguish their nature, short of removal followed by microscopic
examination. Of the symptoms liable to be caused, huskiness is the most
prominent. These neoplasms are rarely large enough to interfere with
respiration, and do not seem ever to give rise to pain.

The diagnosis of laryngeal phthisis is as a rule not very difficult. Perhaps
the most common appearance met with is the pyriform swelling of the ary-
epiglottic folds. The pale colour and characteristic shape make this form
readily recognisable. A localised sessile tumour in the inter -arytenoid
region is suggestive of tuberculosis, but syphilitic ulcers occasionally occur
in this situation, and the upper margin may become the seat of granula-
tions which conceal the ulcer from view. When the epiglottis is infiltrated

LAKYNX, CHRONIC INFECTIVE DISEASES 363

the pale colour and turban shape are very characteristic, and unlikely to be
mistaken. Again, the eaten-out edges of the vocal cords and the longi-
tudinal ulceration, giving rise to an appearance of cleavage, are strongly
suggestive of phthisis. Finally, the presence of pulmonary disease and the
existence of tubercle bacilli in the sputum will in most cases give corrobora-
tive evidence.

In the early stages the presence of localised redness and swelling may
afford grounds for suspicion, but not for a definite diagnosis. In cases of
laryngeal phthisis the pharynx is often markedly anaemic, and sometimes
the unusually pale mucosa is relieved by dilated vessels coursing over it —
an appearance very suggestive of threatened or actual tuberculosis. I have
not referred to injections of tuberculin as of value in diagnosis, since they
can hardly be considered justifiable after past experience.

The prognosis of laryngeal phthisis is extremely grave, but it must not
be forgotten that many cases of cure have been recorded. The prospect for
the larynx is better according as the lung lesion is slight or improving, and
vice versa. Moreover, much can be done by treatment to retard even if it
does not cure.

Treatment. — In considering the therapeutics of laryngeal phthisis I shall
refer merely to those points which relate to the special condition, leaving
it to be understood that suitable general treatment must be carried out.

One of the first questions that usually confronts us in connection with
phthisis is whether the patient should be sent to winter abroad. In
selecting a climate for a case of laryngeal phthisis, as a rule, three points
should be considered, viz. : (1) Warmth and sunshine ; (2) the air should
have a degree of humidity ; (3) there should be little dust. As examples of
places fulfilling these indications may be mentioned Madeira, Pisa, Capri,
and the Canary Islands. It was formerly supposed that high altitudes
were always contra-indicated where the larynx had become involved, but,
as pointed out by Clinton Wagner, this is not always the case. The effect,
however, should be carefully watched if the experiment be tried. Under
certain circumstances it may be desirable to place the patient in one of the
institutions which are now springing up in this country, and which have
long existed in Germany, e.g. Falkenstein, Eeiboldsgriin, Gorbersdorf, where
the open-air treatment is carried out on scientific lines, and where the
necessary local remedies can also be employed.

As to general hygiene and regimen — the voice should be saved as much
as possible, and a nourishing, wholesome diet given, while smoking should
be altogether forbidden indoors. At the same time a cigar or pipe smoked
in the open air may usually be permitted. When dysphagia is a marked
symptom the administration of all nourishment often becomes difficult. In
such cases it will be found that soups, thickened with arrowroot or an
equivalent, raw eggs and milk, calf-foot jelly, and sometimes ices, will be
acceptable. A little culinary ingenuity will suggest food of a suitable con-
sistence, i.e. semi-solid, and of sufficient variety, while where cold is well
borne nutritious materials may be incorporated with ices. Wolfenden
found that patients in whom dysphagia is severe may be enabled to swallow
in comparative comfort by lying on the face with the head over a bed or
couch, and sucking up food from a basin held below the mouth and con-
nected with it by a tube.

It is sometimes, however, necessary to resort to local ansesthetics, such
as cocaine, 10 to 20 per cent applied with a spray or brush, and eucaine. A
solution of from 20 to 30 per cent of menthol in paroleine may also be
employed for this purpose, by syringing it into the larynx. When painful

364 LAEYNX, CHEONIC INFECTIVE DISEASES

deglutition is due to ulceration, orthoform blown on to the affected part is
often very successful, the anaesthesia sometimes lasting for many hours.

Local treatment applied to the larynx with the object of arresting or
curing the disease should be adapted to the condition of the patient. Thus, if
the pulmonary disease be advanced and the patient weak and emaciated, it
is well to avoid all active treatment of a painful kind. Volatile substances,
such as balsam of Peru, may then be employed, added to hot water and the
steam inhaled, or a spray of from 5 to 20 per cent of menthol in paroleine
may be used. As pointed out by Eosenberg, however, this drug is best
used by means of a syringe with which a drachm or more of a 20 per cent
solution in oil may be injected into the larynx. The insufflation of anti-
septic powders which may be mixed with orthoform or morphia, if these be
indicated by the presence of pain, may be employed in persons who are no
longer sufficiently robust to tolerate more active treatment. Equal parts
of boracic and iodoform have been recommended, and Lublinski has had
satisfactory results from iodol. There can, however, be no doubt that lactic
acid as first suggested by Krause is the best local remedy we possess.

Its great efficacy in ulceration is admitted by all, but there can be no
doubt that it is also beneficial in infiltrations. Lactic acid should be first
used in 20 per cent solution, but gradually this should be strengthened,
until, if well tolerated, it is employed in a strength of 80 per cent. It is
best applied by means of a cotton-wool holder, and should be rubbed well
into the parts. As a general rule, when the stronger solutions are used
several days should elapse between the applications.

Various other active remedies have been suggested, and no doubt in some
cases they may act well, e.g. sulforicinic solution of carbolic 30 per cent
(Euault), oleaginous solution of creasote and menthol (Chappell), para-ortho
and mono-chlorophenol (Simanowski, Spengler, and Hedderick), from 5 to 20
per cent dissolved in glycerine, and concentrated solution of iodoform in
equal parts of alcohol and ether, recommended by Newman as a spray.

Of late years surgical treatment of laryngeal phthisis has come much
into vogue and has given excellent results, especially in the hands of
continental authorities. It goes without saying that operative measures
are only justifiable in patients whose strength has been well maintained and
in whom the pulmonary disease is not actively advancing. The objects
aimed at are — (1) The removal of infiltrations; (2) Curetting ulcerated
surfaces. Heryng may justly claim to have been a pioneer in this matter,
and his instruments, together with the double curette of Krause, are gener-
ally employed. Some laryngologists, however, use the electric cautery, and
even electrolysis. Schmidt formerly recommended multiple incisions
followed by the application of lactic acid, while he was also an advocate of
tracheotomy in certain cases. Submucous injections of lactic acid, creasote
diluted with oil, etc., have also been advocated. In suitable cases, however,
curetting soft tissue and ulcerated surfaces, together with the removal by
means of the double curette of infiltrations, seem to have given the best
results — more particularly when these operations were followed by appli-
cations of lactic acid.

In the case of tubercular tumours without infiltration the removal of
the neoplasm is indicated, and must be carried out by one of the methods
discussed in another portion of this work.

Lupus of the Larynx

As lupus is in a sense a form of tuberculosis the reader may pertinently
ask why it is discussed under a separate heading. The reply lies in the

LARYNX, CHRONIC INFECTIVE DISEASES 365

clinical differences which exist between what we may term true tuberculosis
and the form known as lupus.

It was formerly held that lupus of the larynx is usually secondary to
lupus of the skin of the face. My own experience has shown me that it is
by no means uncommon to find the affection confined to the mucous
membrane of the nose and throat, while sometimes it develops only in the
larynx.

The disease certainly attacks by preference young females, but it may
occur both in boys and in men of early middle age.

Lupus of the larynx produces extremely slight symptoms, and, indeed,
may cause none unless the infiltration be so situated as to interfere with
phonation, or much more rarely, respiration.

The part most frequently affected is the epiglottis, but the characteristic
infiltration may appear on other parts as well, e.g. the ary-epiglottic folds,
posterior wall, ventricular bands, and true cords. On examination the
parts affected are seen to be thickened and nodular. Individual nodules
vary in size from a pin-head to several times as large. They are situated
close together, so that the whole affected area is studded with them. It is
stated by most authors that after a time slow ulceration sets in followed by
cicatrisation, and that sometimes fresh nodules appear on the surface of
such cicatrices. My own impression is that it is extremely doubtful
whether there is in lupus of mucous membranes any tendency towards
breaking down by breach of surface.

If the part be so situated as to be exposed to injury, then of course
infection and surface ulceration may result.

The diagnosis is not as a rule difficult. The nodular character of the
infiltration, which is usually of a bright red colour, the absence of any pro-
nounced tendency to ulceration, and the painless, slow course are more or
less pathognomonic.

The prognosis of this affection is somewhat uncertain. While some
cases seem to be readily checked for a time at least, or even cured by general
and local treatment, others are most obstinate. The course of the malady
is always a slow one, but gradually it may lead to loss of voice and even to
dyspnoea.

The chief indication for treatment is to remove the diseased tissue or
destroy it with the electric cautery. For the former purpose the instru-
ments already referred to in discussing laryngeal phthisis may be employed.
The cautery, however, sometimes acts beneficially, not only upon the part
burned, but upon surrounding nodules. Lactic acid, too, I have found very
serviceable. Together with local remedies general treatment must be pre-
scribed. Fresh air, milk, arsenic, and cod-liver oil are specially indicated.

I am not sure that in obstinate cases of laryngeal lupus it might not be
justifiable to resort to Koch's original tuberculin. In one of my cases
treated by this method rapid cure resulted, although a considerable degree
of laryngeal stenosis resulted, and this had to be treated by dilatation.

Syphilis of the Larynx

The larynx is more commonly affected by acquired than by inherited
syphilis, and it has been shown by statistics that syphilitic males are more
prone to be attacked than females.

Clinical Features. — As in other parts, so in the larynx, the disease may
appear in many forms.

Syphilitic catarrh, while commonly an early symptom, may recur at later

366 LARYJSTX, CHRONIC INFECTIVE DISEASES

periods throughout the disease. The appearances are rarely distinctive,
although sometimes there is a patchy redness which is highly suggestive.

Much more characteristic is the presence of mucous patches, which
appear as whitish areas on various parts of the larynx, and may result in super-
ficial ulceration. Very rarely true condylomata may be found in the larynx,
and G-erhardt quotes a case observed by Heymann in which they were so
numerous as to cause marked dyspnoea. As a rule these earlier manifesta-
tions give rise only to huskiness and some local discomfort.

Gummata frequently occur in the larynx, but as a general rule they
are not observed until ulceration has set in. Three forms are usually
described, viz. (1) Relatively large rounded growths ; (2) Groups of small
nodules ; (3) Diffuse infiltration. They cause symptoms in proportion to
their size and situation.

Commonly they tend to break down rapidly and give rise to deep
ulceration. The margins of the ulcer are generally raised, while the floor is
of a whitish colour owing to its being covered with detritus. The mucosa
immediately surrounding it is red and swollen. These tertiary ulcers have
a great tendency to spread both in width and in depth. The epiglottis is
often attacked, and frequently destruction of the whole or at least of a
large portion of this organ results. Again, the true and false cords may be
the seat of disease, and one or both sides of the larynx may be extensively
destroyed.

Tertiary ulcers of the larynx invariably leave more or less marked
changes after they heal. Thus in extreme cases great narrowing of the
lumen of the glottis may occur, while the various parts of the larynx are
so altered as to be hardly distinguishable. Again, not uncommonly a
cicatricial web occludes more or less of the space between the cords, which
may themselves be so changed as to be recognised with difficulty. Some-
times, as a result of ulcers near the arytenoid cartilages, these become fixed,
and an appearance is produced which by the casual observer might be taken
for recurrent paralysis.

When, instead of healing, ulceration tends to extend, perichondritis may
result, and occasionally oedema supervenes and renders a rapid resort to
tracheotomy necessary. The symptoms of laryngeal syphilis are as a rule
not very marked. In the catarrhal stage huskiness and mere discomfort
only are experienced. Very rarely, as we have seen, condylomata may occur
and lead to dyspnoea during the second period. Gummata may, according
to their situation, lead to hoarseness or dyspnoea. When ulceration has
become established more or less pain may be complained of, the breath be-
comes foetid, and hoarseness is often pronounced. If the epiglottis only be
involved, difficulty in swallowing may be a marked symptom, but even the
total disappearance of this part does not, per se, cause any permanent inter-
ference with deglutition.

The diagnosis of laryngeal syphilis is usually easy if other evidences of
the disease be present, e.g. cutaneous, lymphatic, buccal, or pharyngeal.
As we have seen, specific catarrh may not have any distinctive characters.
Mucous patches may be simulated by herpes, but more particularly by
pemphigus after the blebs have burst. It is, therefore, not a simple matter
to diagnose even the earlier forms unless we have a definite history or
other manifestations. The same difficulty confronts us more frequently
with regard to tertiary conditions. As a general rule gummatous infiltra-
tions are of a red colour, while frequently tubercular deposits are pale.
When the stage of ulceration has been reached, therefore, the syphilitic
ulcer is surrounded by a raised angry red zone. Moreover, it is often

LARYNX, CHRONIC INFECTIVE DISEASES 367

single, its floor is covered with whitish detritus, and it spreads with great
rapidity if no constitutional treatment be adopted. Occasionally both in
tubercle and syphilis an ulcer is found in the inter-arytenoid fold. So far
as I know, the appearances are identical, and diagnosis must then depend
upon the condition of the lungs, the presence or absence of tubercle bacilli
in the sputum, and of other evidences of syphilis. On the other hand,
extensive deep ulceration of the epiglottis spreading from its lingual surface
is usually specific. Infiltrations which have begun to break down may also
be mistaken for malignant disease, and in some cases only the effect of
antisyphilitic remedies can determine the true nature of the affection.

Primary lupus of the larynx differs from syphilis in that the infiltration
is uniformly nodular and does not tend to break down — or at least if
ulceration occurs its progress is excessively slow. Moreover the patients
are commonly young persons, although not always. Leprosy only occurs
in the larynx as part of the general disease, while in scleroma there is no
tendency to ulceration.

The treatment of laryngeal syphilis must, of course, be constitutional.
Mercury by the mouth or by inunction should be employed in the secondary
stages, while in the tertiary period our main reliance must be placed upon
iodide of potassium. It is, however, well to remember that sometimes even
in late manifestations a course of mercurial inunction, either at home, or
preferably at Aix-la-Chapelle if means permit, may expedite a cure.

If syphilitic catarrh be obstinate it may be treated by the local applica-
tion of solutions of chloride of zinc or nitrate of silver (gr. 20 ad §j.).
When ulceration has occurred a spray of corrosive (1-2000), of boracic (gr.
10 ad 5J.), or of menthol in paroleine (5 per cent) may be ordered. If ulcers
refuse to heal they may be touched with nitrate of silver or chromic acid.

It is of great consequence, when extensive destruction of tissue has
occurred, to prevent as far as may be subsequent stenosis. It may there-
fore be necessary during this period to dilate the larynx with Schroetter's
bougies, or possibly the introduction of an O'Dwyer's tube may be indicated.
If the case be only seen after stenosis has occurred it must be treated
according to the rules laid down in another part of this work.

Scleroma of the Lakynx

This disease, probably due to the bacillus discovered by Frisch, rarely
if ever occurs in the British Isles ; indeed it seems to be confined to
certain well-defined areas. It is common in the south-west of Russia and
adjacent provinces over the borders, it has also been met with in Central
America and the Antilles.

In the larynx the subglottic space is most frequently attacked. As a
rule two symmetrical hard swellings appear below the cords. In colour
they are gray or pink, while when touched with a probe they are felt to be
of very firm consistence. Infiltration may, however, involve the ary-
epiglottic folds and ventricular bands, and occasionally other parts also.

Ulceration does not seem to occur, but gradual cicatrisation may take
place.

The symptoms vary according to the parts affected. Thus huskiness
may occur first in one case and dyspnoea in another. The last named will,
however, sooner or later set in, as even if the laryngeal stricture be dilated,
the disease tends to spread to the trachea and finally to the bronchi.

The only treatment which seems to avail is surgical interference. Thus
persistent dilatation may prevent the occurrence of dangerous stenosis for a

368 LAEYNX, BENIGN GEOWTHS OF

time at least, while at a later stage tracheotomy may be required. Paw-
lowsky has advocated the employment of a liquid prepared from the bacillus
which he terms rhinosclerin.

Leprosy of the Larynx

This disease only attacks the larynx after it has already become manifest
in other parts.

Infiltration may occur in any position, although the epiglottis is stated
to suffer most frequently. The ary-epiglottic folds are also often involved,
and by their traction produce further changes in the shape and position of
the epiglottis. According to Bergengrun the part is drawn backwards,
its edges are turned in, and the contour resembles the Greek omega (12).
At a later period more circumscribed granulomata occur in various parts.
These vary much in shape, size, and consistence. Thus they may be smooth
or granular, sometimes even resembling papillomata. They may be only
as large as a pin-head, but have been met with up to the size of a pigeon's
egg. According to Bergengrun they are always anaesthetic. These leprous
nodules seem to have usually a more or less pale colour, while although
firm at first they become softer as time goes on. As a rule the vocal
cords seem to escape for a time, but if the patient survives they become
first infiltrated and they later develop nodules.

As the disease advances ulceration sets in ; the ulcers may be deep and
spread rapidly, or superficial, while sometimes clefts and furrows occur in
the infiltrated parts. Finally, cicatrisation may occur at parts although
the disease progresses elsewhere.

The more important symptoms are, as would be expected, huskiness in
the early stages and dyspnoea later.

As the general disease is always present this facilitates diagnosis. The
chief distinctive points in the local lesions are — (1) The very slow progress ;
(2) anaesthesia ; while in doubtful cases the bacillus leprae may be discovered
in a removed fragment.

The treatment must be purely palliative and tracheotomy may become
necessary.

Benign Growths of Larynx

Introductory .

. 368

Diagnosis

. 372

Varieties of .

. 369

Course and Prognosis .

. 372

Etiology .

. 371

Treatment

. 373

Clinical Features .

. 371

The opinion has been often expressed that benign growths of the larynx
are met with less frequently now than in the early days of laryngology,
and it has been suggested that this is due to those throat ailments
which favour the formation of neoplasms, now receiving earlier and more
efficient treatment. Leaving aside the fact that we do not know what
" throat ailments favour the formation of neoplasms," we are not aware of
any reliable evidence showing that the frequency of simple growths of
the larynx has diminished in this country. When we remember that
Mackenzie, when he was almost the only worker in the field, took ten years
to collect his first hundred cases, that these cases are now divided among
many workers throughout the country, and, further, that the majority are
never published, the alleged diminution will at least appear doubtful. Still,
there is no doubt that simple laryngeal growths, if we except the so-called

LARYNX, BENIGN GROWTHS OF 369

" singers' nodule," are comparatively rare. Newman gives the percentage
as from two to two and a half of all chronic laryngeal diseases, and Lennox
Browne puts it at 2-5 per cent of all diseases of the larynx.

Of the many varieties of new growths which have been met with in
the larynx only three are of frequent occurrence — papilloma, libroma, and
cystoma. All the others, such as lipoma, angioma, chondroma, adenoma,
myxoma, lymphoma, and thyroid gland-tissue tumours, are very rare. It
is usual to describe the so-called " singers' nodule " as a distinct clinical
variety of new growth, since its histological structure varies in different
specimens.

Papilloma. — From Semon's collective investigation statistics this has
been proved to be the commonest form of laryngeal growth, though many
observers have found fibromata to form a much larger proportion of their
cases. It may be single or multiple, and may grow from any part of the
larynx, though most frequently from the vocal cords, rarely from the
epiglottis, and hardly ever, even in the multiple papillomata of children,
from the inter-arytenoid region. The growths may be broad-based, flat,
and firm, but more frequently are more or less pedunculated, cauliflower-
like masses, of softer consistence. They vary in size from a millet seed to
a walnut, and may be white, pink, or red in colour. They are, as a rule,
easily recognised by their distinctly irregular warty surface.

Fibkoma. — This is almost invariably a single growth, with smooth surface,
rounded or semi-globular in shape, occasionally lobulated, often distinctly
pedunculated, but more frequently sessile, and may be grayish white, pink,
or dark red in colour. The consistence of fibromata varies from a hard
nodule to a soft, cystic-looking growth. Histologically they consist of
connective tissue and elastic fibres, with a covering of epithelium, and in
the softer varieties are found cavernous blood spaces, serous infiltrations,
and hemorrhages. In the vast majority of cases the growth arises from
the edge of one of the cords, sometimes from the upper surface or anterior
commissure, rarely from the ventricular bands, ary-epiglottic folds or
epiglottis. In two cases only have they been seen to originate from the
inter-arytenoid region. At times the pedicle is long and thin so that the
growth drops beneath the cords on inspiration, and is thrown on to their
upper surface in forced expiration. They may be of minute size (singers'
nodule), or large enough to fill the cavity of the larynx.

This form of growth can usually be easily recognised by its smooth
surface, and its origin from a vocal cord. At times, however, it is difficult
to distinguish a small soft fibroma from a cyst.

Cystoma. — This form of growth, though much rarer than the two
former, is by no means uncommon. Its most frequent situation is the
anterior surface of the epiglottis, where it is often j overlooked as it may
not give rise to any symptoms. Cysts may also originate, though rarely,
from the edges of the cords. It is probable that most cases recorded in
this situation were really fibromata which had undergone cystic degenera-
tion. They have also been seen to grow from the ventricles, the ary-
epiglottic folds, and the posterior wall of the larynx. They may be broad-
based or pedunculated, and are smooth, globular, semi-transparent growths,
of grayish pink, yellowish, or red colour. They are of the nature of
retention cysts, and arise from obstruction of the ducts of the mucous
glands. Jurasz has suggested that, in those at the base of the tongue,
the obstruction is probably caused by particles of food, as in this situation
there is rarely any evidence of inflammation.

A cyst can generally be recognised by its globular shape and trans-
vol. vi 24

370 LARYNX, BENIGN GROWTHS OF

lucent appearance, with the distended vessels coursing over its surface.
But often its true nature is only discovered on attempted removal. Small
cysts on the vocal cords can only be distinguished from degenerated
fibromata by microscopical examination.

Sin gees' Nodule. — This term has been applied to minute growths which
often form on the edge, or upper surface, of one or both cords in singers,
especially tenors and sopranos, and in female teachers. The name, how-
ever, is an unfortunate one, as they are also to be seen at times in children,
and in persons who do not use their voices professionally. They are
distinguished clinically by their minute size, and their situation at the
junction of the anterior and middle thirds of the vocal cords. Histo-
logically these growths may be minute fibromata, or cysts, or simply
epithelial thickenings. Occasionally there is only one nodule, but more
frequently there are two seated symmetrically at the point mentioned, or
there may be three or four along the edge of one cord. They are seldom
larger than a pin-head, and are greyish-white or pink in colour.

In a very small proportion of cases these nodules have been found to
be cystic, but the great majority are simply inflammatory thickenings, and
should rather be considered as a variety of pachyderma laryngis than as
true new growths.

Lipoma. — Of this rare form of growth only ten cases have been re-
corded. It is usually a large, solitary growth, filling the entrance to
the larynx, and more or less obstructing both breathing and swallowing.
The tumour may be smooth, lobulated, or branched, of pale pink or
yellowish colour, elastic consistence, broad based or pedunculated, and
freely movable. They have been observed to grow from the epiglottis,
ary-epiglottic folds, and posterior wall of the larynx.

Seifert is of opinion that if we find a large, pale pink, slow-growing
tumour, at the entrance to the larynx, we may conclude it is a lipoma.

Angioma. — Of this form of growth under twenty cases are on record.
It is usually a single, sessile growth, very rarely pedunculated, varying in
size from a lentil to a cherry, and of a bright or dark red colour. Its
commonest situation is on the vocal cords, but it has also been seen on the
ventricular bands, in the ventricles, and on the ary-epiglottic folds.

The appearance of the growth is unmistakable, and Browne has noted
as characteristic that the colour of the same growth varies at different
times from white or pale pink to florid red.

Myxoma. — Considerable doubt exists as to whether a true myxoma
ever occurs in the larynx. It is probable that the growths described as
myxomata were really degenerated fibromata, as held by Eppinger.

In the cases recorded the growth originated almost invariably from the
cords, was of a grey or pink colour, pedunculated or sessile, of a jelly-like
transparency, and varying in size from a pea to a cherry. In some the
surface was mammillated, and the growth looked like a papilloma.

Chondroma. — Cartilaginous tumours are rarely met with in the larynx,
as only about fifteen cases have been recorded. They may grow from any
of the laryngeal cartilages, but most commonly from the cricoid. They
are hard, sessile growths, flat or irregular in outline, and covered by
normal mucous membrane. They are usually solitary, rarely multiple,
and tend to grow into the cavity of the larynx. They may be dis-
tinguished by their intense hardness, slow growth, and the absence of
inflammatory symptoms.

Among the exceedingly rare growths which have been met with in the
larynx are lymphoma, adenoma, and thyroid gland tumours, and in one

LARYNX, BENIGN GROWTHS OF 371

instance a growth removed by Schroetter was found composed of muscle
tissue.

Etiology. — We are still as far as ever from settling the question of the
cause of laryngeal growths. That papillomata, cysts, and epithelial
thickenings are occasionally congenital, is beyond doubt. Inheritance and
constitutional predisposition have been suggested, in explanation of cases
where several members of the same family have suffered, and it has been
held (Oertel) that, in the case of papillomata, scrofula and hereditary
syphilis are important factors. The vast majority of observers are agreed
that chronic laryngeal congestion is the most frequent cause of benign
neoplasms, and consequently chronic catarrh, excessive or wrong use of
the vocal organs, the inhaling of dust-ladened air, smoking, the abuse of
alcohol, and the acute infectious diseases, have all been held responsible for
their occurrence. Schech, Jurasz, and others have actually seen new
growths to arise during a chronic laryngitis. On the other hand,
Schroetter and Semon have not found this view supported by their own
cases, and regard the congestion as rather the result of the presence of a
growth than the cause. It is rather curious that syphilis and tubercle,
two of the commonest causes of laryngeal congestion, should be so
generally held to have no bearing on the occurrence of true neoplasms.
I have notes of two cases, one of multiple papillomata, and another of
fibroma, in which the growths appeared while the patients were suffering
from chronic laryngitis of syphilitic origin. That nasal obstruction may
favour the occurrence of growths is quite probable, but that the removal
of tonsils and adenoids, as has been suggested, will cause the growths to
disappear, I do not believe after seeing cases in which these measures have
been adopted.

Beyond all question age and sex are the two most important etiological
factors. At all ages males are more subject than females in the proportion
of three to one. As to age, if we omit the first years of life, there is a
steady increase in frequency up to the age of 40, followed by a decline as
age advances. By far the largest number of cases occur between 30 and
40 years of age, while the period 20 to 50 may be said to be that within
which there is a liability to benign growths of the larynx.

The symptoms produced by a laryngeal growth will depend on its size,
its situation, and the nature of its attachment. In 95 per cent of cases it
is hoarseness, or aphonia, which causes the patient to seek advice. This
arises from the fact that the vast majority of growths originate from the
vocal cords. A very small growth on the edge of a cord will cause
hoarseness, and one at the anterior commissure may produce complete
aphonia, while a growth with a broad attachment will almost certainly
disturb the voice more than one with a narrow pedicle. Diphthonia, a
rare form of vocal disturbance, was first described by Turck. It occurs
where a growth on the edge of one cord divides the glottis into two
unequal portions, and consequently two notes of different pitch are heard
together.

Dyspnoea is present in about one third of all cases, and is most common
in multiple papillomata and in large growths such as lipomrta.

Dysphagia is very rare, and only occurs in large growths at the entrance
to the larynx.

A feeling of something obstructing the larynx, and giving rise to a
frequent desire to clear the throat, is not unusual, but cough is a rare
symptom. At times, however, it is severe and paroxysmal, when the
growth has a long pedicle which allows of its free movement.

372 LABYNX, BENIGN GBOWTHS OF

In a unique case, reported by Sommerbrodt, severe epileptic seizures,
which had resisted all treatment, were cured by the removal of a large
fibroma.

There is never any pain complained of in simple growths, and
the general health is unaffected, except of cases of severe cough or
dyspnoea.

Diagnosis. — Though we may suspect the presence of a laryngeal
growth from the symptoms, the only certain method of diagnosis is by a
laryngoscopic examination. As a rule this will not only reveal the
presence of a growth, but also enable us at once to determine its character.

Only the very inexperienced will mistake the excrescences around a
tubercular or syphilitic ulcer for a new growth. The warty growth in the
inter-arytenoid space, so common in laryngeal phthisis, can hardly be
mistaken for papilloma, as in this situation papillomata are practically
never found. At the anterior commissure, however, I have known a
tubercular tumour to be indistinguishable from a simple growth, till the
microscope revealed its true nature. Such cases, however, are rare, but a
difficulty will more frequently arise in distinguishing a simple from a
malignant papilloma at an early stage. The importance of this subject
demands a fuller statement, and attention to the following points will
assist us in making a diagnosis : —

1. Age of patient. — Simple growths rarely originate after fifty years of
age, therefore the presumption is strongly in favour of malignancy, if the
growth is recent in a patient over that age. Under forty malignant disease
of the larynx is exceedingly rare.

2. Situation of the growth. — Simple growths, except multiple papil-
lomata, are confined to the anterior two-thirds of the vocal cords in the vast
majority of cases, and practically never occur in the inter-arytenoid region.
A single growth on the ary-epiglottic folds, epiglottis, or neighbourhood of
the vocal processes, especially in patients over forty-five, is strongly
suspicious of malignant disease.

3. Simple growths appear to grow out of, malignant growths to invade,
the parts in which they are situated. — This is a sign of great value to the
practised eye.

4. A malignant growth has generally an inflamed base, or the whole
cord on which it is situated may be hypereemic.

5. Any interference with movement of the cord on which the growth is
situated, not due to purely mechanical causes, will be strongly presumptive
of malignancy.

6. The tendency to ulceration of malignant growths, even at an early
stage, will often settle the diagnosis.

Course and Prognosis. — The natural history of a simple laryngeal
growth will depend principally on its character. Fibromata, after attaining
a certain size, generally remain stationary for years, though very rarely
they continue to grow till they come to obstruct the breathing. Papil-
lomata may be divided into two kinds ; in the one there does not appear to
be any tendency to rapid growth, even when multiple ; in the other they
appear to have almost a malignant character, recur rapidly when removed,
and spread down the trachea, to the edges of the tracheotomy wound, and
along the cicatrix left after a thyrotomy. The latter form is mostly "seen
in young children, the former in adults.

From the small number of cases of papilloma seen between the ages of
10 and 20, I am of opinion that in the larynx as elsewhere, these growths
tend to disappear at puberty, and this view has been confirmed by my own

LARYNX, BENIGN GROWTHS OF 373

observations as well as by others. That they may also remain from child-
hood throughout adult life is shown by a case which I saw some years ago.
A gentleman, aged 63, had lost his voice at the age of 10 after an
attack of measles. He had gone through life practically voiceless, and
without ever having his larynx examined. I removed a large number
of papillomata from the edges of the cords and anterior commissure, which
have shown no tendency to recur.

Papillomata have been noticed in a few instances to disappear after
attacks of acute infectious disease, and many times after tracheotomy.
Laryngeal growths have also been coughed up, or have sloughed off
through the pedicle becoming twisted. On one occasion a lady, from whom
I removed a large fibroma growing from the ventricle, brought me a
similar growth which she had coughed up four years previously, and had
preserved in spirit.

The only danger to life arises from the sudden onset of asphyxia,
and although this can generally be prevented by a timely tracheotomy, I
know of several cases among the children of the poor where death has
resulted from suffocation.

As to restoration of voice, prognosis is very good on the whole, but in
multiple papilloma, and in growths with broad attachments, the voice is
not likely to regain its full range and purity. In the case of singers and
other professional voice-users, the prognosis should be very guarded, if the
growth springs from the cords, or if there is much catarrhal thickening.

As regards recurrence, it is only to be feared in papilloma. A fibroma,
once thoroughly removed, does not recur, and the same is true of other
simple growths. Papilloma, however, may even recur after the larynx has
been free for years. The question of the malignant degeneration of benign
growths has been finally settled by the collective investigation instituted
by Semon. That such a transformation may occur is possible, but it is an
event of the greatest rarity, and one which is in no way influenced by
intralaryngeal treatment.

Treatment. — It may be regarded as certain that no internal treatment
has any influence on the progress of laryngeal neoplasms, though arsenic
has been said to have a specific influence on papillomata. Cases have been
recorded of growths disappearing under the use of astringent or alkaline
sprays. These were no doubt purely inflammatory products, and vocal
rest may have had as much to do with the result as the local application.
An exceptional case is that reported by Delavan, in which a large papilloma
disappeared completely under the prolonged use of a spray of absolute
alcohol.

Except in the case of " singers' nodule," which is often cured by prolonged
rest of the voice, we may say that practically all laryngeal growths require
operative treatment for their removal. In a small number of cases,
however, the growth may be left alone, either because it produces no
symptoms, or because the symptoms are so trifling that the patient is un-
willing to submit to operation. Examples of this sort which have come
under my notice have been epiglottic cysts, and small fibromata of the vocal
cords.

The introduction of cocaine has done much to simplify all intra-
laryngeal operations, and to shorten, or do away with the need for, the
preliminary training of the patient. It has, however, by no means
removed all difficulties, or made it safe for any but those who have
undergone prolonged training of eye and hand, to undertake these
operations.

374 LAEYJSTX, BENIGN GBOWTHS OF

A great variety of instruments, forceps, knives, curettes, guillotines, and snares,
have been employed in the removal of laryngeal growths ; and while the choice
of instrument will partly depend on the situation, size, and nature of the growth
to be removed, the individual preference of the operator is probably the most
important factor. It is unnecessary to describe in detail all these instruments ;
but we may state that two, a cutting-forceps and a snare, will be found sufficient
for all purposes. In fact, we might almost say that the former alone is sufficient,
as the chief merit of the snare is that with it one can scarcely do any harm. It
is occasionally of use, however, in the difficult growths at the anterior commissure.
I have never seen the advantage of a large and powerful forceps, such as that of
Mackenzie, though it has always been the favourite instrument in this country ;
and the right-angled curve, which he adopted in order to avoid touching the
epiglottis, is no longer required with cocaine anaesthesia.

The delicate, catheter-curved instruments, such as the forceps of Schroetter or
Jurasz, or the double curette of Krause, permit of all manipulations being com-
pletely controlled by the eye, and can be used to raise the epiglottis so as to get
at growths in the anterior commissure. Another advantage of Schroetter's forceps
is that, being made of soft metal, the curve can be altered so as to make the
instrument suitable for growths in any part of the larynx. Whatever forceps be
used, the blades should be well sharpened, so that the growth is cut off and not
torn away. The so-called " safety-forceps " of Dundas Grant has been highly
spoken of for growths on the edges of the cords, and I know of no objection to
this instrument beyond its name. " Safety " must lie in the trained hand and
eye of the operator, and not in the instrument he employs. Though caustics are
no longer employed for the destruction of growths, the galvano-cautery has still
its advocates. In the case of angiomata, or other highly vascular tumours where
bleeding is feared, it may be a serviceable instrument, but there is always a risk
of doing permanent injury to the voice when it is used on a vocal cord.

The multiple papillomata of young children present special difficulties in the
way of treatment. That thyrotomy would prove the best method of dealing with
many of them there is little doubt, if we knew how to prevent recurrence. Till
we can do this I think that, on the whole, Semon's advice is the best : to perform
a tracheotomy as soon as it becomes necessary, and then to wait till the child is
old enough to permit of intra-laryngeal treatment. In a very small proportion
of cases the growths may disappear spontaneously after the larynx has been put
at rest by the tracheotomy. This plan of waiting, however, is not always so
successful as one could wish, and more than once I have advised thyrotomy, as the
health of the child has suffered while wearing a cannula, or frequent attacks of
bronchitis or broncho-pneumonia have become a source of danger. Two methods
of operating which have been introduced in recent years promise to be of value
in these difficult cases. One is the method of Scanes Spicer for operating under
chloroform anaesthesia, combined with the local application of cocaine to arrest
the secretions of the larynx and pharynx ; the other is the direct method of
Kirstein. Both have been successfully adopted in a few cases, and will no doubt
at times enable us to avoid a tracheotomy.

Apart from cases of multiple papillomata in children, external operation will
scarcely ever be necessary in the treatment of benign growths. The rule is that
"an external operation in a case of a benign growth of the larynx is only
indicated when an experienced laryngologist has failed to remove the neoplasm
per vias natwales." The number of cases coming under this category will be
exceedingly small, and is practically confined to sessile subglottic growths of
great rarity.

Sub-hyoid laryngotomy has been employed in a few cases for the removal of
large growths situated at the entrance to the larynx. In the case of simple
growths this operation is never called for, as removal through the mouth is
always possible, either with or without a preliminary tracheotomy.

_ To prevent the recurrence of papillomata many applications have been tried.
Nitrate of silver, chromic acid, the electric and thermo-cautery, have all proved
unavailing. Pure lactic acid, as recommended by Schmidt, has been of most
value in my experience.

LITERATURE. — 1. Mackenzie. Growths in the Larynx. — 2. Schwarz. Des Tumeurs
du Larynx, — 3. Semon. The Clinical Journal, Feb. 20, 1895. — 4. Hunt. Journal of
Laryngology, Aug. 1897. — 5. The text-books of Browne, Schech, Gottstein, Schmidt, and
Schroetter.

LARYNX, MALIGNANT DISEASE OF

375

Malignant Disease of Larynx

Definition and Introductory

From Syphilis

383

Eemarks

375

Tuberculosis

384

Etiology ....

375

Lupus

385

Pathology

377

Pachydermia Laryngis

385

Symptoms ....

377

Laryngeal Paralysis .

386

Diagnosis ....

380

Prognosis .....

386

From Benign Tumours

382

Treatment ....

387

Chronic Laryngitis

383

Definition and Introductory Eemarks. — The term malignant disease
of the larynx comprises the two affections known otherwise as carcinoma
and sarcoma of the larynx. Both are rare, sarcoma even much more so
than carcinoma. According to Gurlt's large statistics, laryngeal cancer
amounts to 0'5 per cent of cancer in general, and the proportion of sarcoma
to carcinoma is as 1 to 11-12. In spite of the rarity of the disease, how-
ever, it is of the greatest importance that the general practitioner, to whom
this class of patients almost always applies at first, should be well acquainted
with the early symptoms. It will be shown that, if recognised in the
initial stages, a much larger proportion of cases of malignant disease of the
larynx can be radically and lastingly cured than is at present considered
possible, whilst if its recognition should be much delayed, owing to the
erroneous notions which, unfortunately, still very generally prevail with
regard to the early symptoms of the disease, the patient's chances are be-
coming much worse, or are even entirely lost.

The description of both carcinoma and sarcoma of the larynx may well
be combined, inasmuch as, with regard to the symptomatology, diagnosis,
prognosis, and treatment, the two forms of malignant growths run so very
similar a course that to describe them separately would entail useless
repetitions.

From the practical point of view, however, it is desirable to adopt the
late Professor Krishaber's terminology, and to distinguish between " intrinsic
and extrinsic carcinoma."

The former variety comprises cancers arising from the interior proper
of the larynx, i.e. from the vocal cords, ventricular bands, ventricles of
Morgagni, and the sub-glottic cavity. Extrinsic carcinomas grow from the
epiglottis, the aryteno-epiglottic folds, the inter-arytenoid fold, and the
posterior surface of the cricoid cartilage. Sarcoma of the larynx much
more frequently belongs to the intrinsic than to the extrinsic variety.

Etiology. — The origin of malignant disease of the larynx is as little
known as that of malignant disease in general. It is still quite uncertain
whether the affection be due to a microbic invasion" or to a developmental
error. A few facts, however, of great practical importance are known with
regard to the natural history of the disease.

First of all, the affection is almost always primary, i.e. it either arises in
the larynx itself or reaches that organ by direct contiguity ; metatastic
or secondary cancer and sarcoma of the larynx, if occurring at all, are
extremely rare.

On the other hand, primary cancer of the larynx has little or no
tendency to secondarily affect the internal organs or distant parts of the
body. But there is that great and, from a practical point of view, most
important difference between intrinsic and extrinsic cancer of the larynx
that, in the former, the lymphatic glands of the neck are only affected very
late in the progress of the disease, and sometimes not at all, whilst, in the

376 LABYNX, MALIGNANT DISEASE OF

extrinsic form, these glands become implicated to a large extent and, as a
rule, at a very early period. Sarcoma of the larynx, as a rule, shows
equally little tendency to affect the lymphatic glands of the neck and the
internal organs of the body.

Secondly, the male sex is undoubtedly much more prone to cancer of
the larynx than the female. In my own experience the proportion is
about three to one, and this, I believe, agrees with the general experience.
At the same time it is extremely curious that whilst amongst my male
patients one-fourth only of the total number suffered from purely extrinsic
malignant disease, considerably the greater half of my female patients were
affected with this much more intractable form of the fell disease, the new
growth usually starting from the posterior surface of the cricoid cartilage.
The causes of these differences are quite obscure ; the facts, however, can be
vouched for.

Thirdly, the overwhelming proportion of all cases of malignant disease
coming under observation is formed by the thirty years of life between 40
and 70, and of these thirty years, again, the decade between 50 and 60
takes up by far the largest individual proportion. Neither younger nor
greater age, however, is spared by the scourge; I have myself seen and
described three cases in which the age of the patient was 80 or more, and
several in which the age was between 20 and 40. My youngest patient
was 27 years old, and recently, by a curious coincidence, I have within
three weeks seen three patients afflicted with laryngeal cancer, whose ages
were between 30 and 35. Even younger patients suffering from laryngeal
cancer have been seen by other observers, and, in a very few cases, even
children have been described as suffering from this terrible disease.

Fourthly, occupation, heredity, and habits, according to my experience,
have no influence whatever upon the production of the disease. It is met
with in the upper classes just as frequently, if not more so, than in the lower ;
the strong are, if anything, more frequently attacked than the weak;
smokers and people addicted to alcohol are not more liable to the affection
than total abstainers; people leading an active life are just as prone as
those whose occupations are sedentary ; and professional voice-users run no
greater danger than silent people.

Fifthly, the assertion that there was a special liability of benign laryn-
geal growths to undergo malignant degeneration, particularly after intra-
laryngeal operation, has been shown by me on the basis of collective
investigation, made amongst the leading laryngologists of the world, to
have been totally unfounded. In 8216 cases of intralaryngeal operation,
five cases only were reported in which such a transformation could be
admitted as certain, i.e. 1 in 1645. In seven further cases the transforma-
tion, though not certain, was probable, and in another ten doubtful, so that
even if the probable and doubtful cases were admitted, in addition to
the certain ones, into the category of malignant degenerations of previously
benign laryngeal growths, the proportion would be as 1 in 373, whilst if the
" certain " and " probable " cases only were admitted, the proportion would
be 1 in 685.

Under any circumstances, there is not the least corroboration by actual
facts of the assertion that there existed a special liability of benign growths
to undergo malignant degeneration after intralaryngeal operation, the less
so as the collective investigation referred to has also shown that actually a
larger number of spontaneous degenerations occurred in non-operated cases
than post-operative degenerations, in cases which had been submitted to
intralaryngeal operation.

LAItYNX, MALIGNANT DISEASE OF 'Ml

Pathology. — By far the greatest number of cases of laryngeal carcinoma
belong to the squainous-celled variety (epithelioma) ; scirrhus and medullary
cancer are infinitely rarer. In one isolated case I have observed columnar-
celled carcinoma, and in one other case villous cancer. Spheroidal-celled or
glandular-celled carcinoma (adeno-carcinoma) I have never seen, but the
latter variety has been described by several observers. The enormous pre-
ponderance of epithelioma observed in my own cases is fully in accordance
with general experience.

Sarcoma occurs in both the round and spindle -celled varieties, and
additionally in combination with other forms of growths, as fibro-sarcoma,
inyxo- sarcoma, and very rarely lympho-sarcoma. The histological char-
acteristics of malignant growths in the larynx in no way differ from those
of analogous tumours in other parts of the body.

Symptoms. — The symptoms of malignant disease of the larynx, includ-
ing both carcinoma and sarcoma, in their early stages vary very greatly
according to the primary localisation of the growth. The still almost
universal notion, viz. that constitutional and grave local symptoms neces-
sarily accompany cancer or sarcoma of the larynx from their very onset, is
absolutely wrong, so far as the more frequent variety, the intrinsic, is con-
cerned, and the sooner this fact becomes generally admitted the better for
the sufferers, and their chances of being saved.

In the intrinsic variety the initial symptoms are very trivial. If the
growth starts from one of the vocal cords, or their anterior commissure, the
first and, for a long time, the only symptom is hoarseness. I have known
a good many cases in which simple huskiness or hoarseness of the voice,
unattended by pain or any other local or constitutional symptom, remained
for a year, or even more, the only symptom of the grave affection. It
should therefore be an invariable rule for every general practitioner to
carefully examine, or have examined by an expert, the larynx of any
middle-aged patient who, for any length of time, has been suffering from
obstinate hoarseness, even if there be no other symptoms of any kind.
The hoarseness in such cases develops gradually, in proportion to the
increase of the growth, and finally ends in complete or almost complete
aphonia. Should, meanwhile, the glottic space have been considerably
encroached upon by the new growth, difficulty of breathing, usually steadily
increasing, but, in a few rare cases, occasionally intensified by violent
spasmodic attacks, makes its appearance^ and if the disease be allowed to
progress without hindrance, usually becomes so severe as to necessitate the
performance of tracheotomy.

Sometimes, however, even when the stage of complete aphonia and con-
siderable dyspnoea has been reached, a temporary fallacious improvement
takes place, owing to peripheral breakdown of the neoplasm. In such
cases temporarily free respiration and almost normal voice may be for a
short time restored, and the patient and his friends may hope that an
erroneous diagnosis had been arrived at. Several such cases are within my
own cognisance. Soon, however, the growth manifests fresh activity, and
the old symptoms return with increased severity.

When once the stage of ulceration has been reached, and not rarely
even long before that time, there is much increased production of phlegm,
usually frothy in character. Later on the expectoration is sometimes
blood-stained, and occasionally little haemorrhages occur. At this period
the breath also often becomes foetid, but even at that time no deterioration
of the general health need have occurred, and there may be no pain, no
difficulty in swallowing, and no enlargement of the cervical glands. It is

378 LABYNX, MALIGNANT DISEASE OF

perhaps here the place for the observation that the significance of pain in
malignant disease has, according to my own experience, which in this class
of cases is exceptionally large, been greatly overstated. In a number of
close upon 200 cases of this kind which I have seen, I hardly remember a
single one in which pain played the predominant role ; often enough it was
either quite insignificant, or even completely absent till the patient's death,
although it must not be denied that in a few cases it was described as an
early symptom.

Should the new growth be allowed to extend and to transgress the con-
fines of the larynx proper, the cervical lymphatic glands, as a rule, become
enlarged and form smaller or larger clusters of hard masses, which vary in
their mobility, and not rarely ultimately become fixed to the neighbouring
parts. Should the oesophagus be affected, dysphagia becomes a prominent
feature. Should the disease extend to the deeper structures and involve
the cartilaginous framework, perceptible broadening of the larynx will be
perceived, and later on symptoms of perichondritis may occur, which in
some cases so entirely overshadow the original disease that the latter can
only be diagnosed with the greatest difficulty or even not at all.

Finally, when the new growth has found its way, either through the
thyro-hyoid membrane or through destruction of the laryngeal cartilages
themselves, into the soft parts surrounding the larynx, smart haemorrhages
may be caused by invasion of the blood-vessels ; violent neuralgia or motor
paralysis may be due to invasion of the nerves of the neck, and finally, the
external integument may be broken through, and the new growth appear
externally as a fungating irregular tumour, which alternates between
breaking down and luxuriantly sprouting, and is often covered with
ichorous pus. In more than one case, in which tracheotomy had been per-
formed, I have seen that the tracheal wound, having been invaded by the
new growth, was gradually enlarged by ever -recurring breakdown of
cancerous vegetations, occupying its borders, until finally the tracheal
cannula was lying in a huge cavity formed by the remnants of the larynx
and the upper part of the trachea, which had been almost entirely destroyed
by the progress of the disease. In such cases, occasionally, almost the
whole or, at any rate, the greater part of the cartilaginous framework is
expectorated during life in smaller or larger necrosed fragments.

The final stages both of the intrinsic and the extrinsic variety, if the
disease has been allowed to take its natural course, are usually those of
general cachexia. In some cases the haemorrhages towards the end get
more frequent and abundant, and the patient sinks from sheer exhaustion ;
in other cases in which the oesophagus has become involved, increasing
dysphagia hastens the fatal end. Not rarely fistulous communications are
being established between the air and food-passages, and the termination is
often brought about by septic pneumonia, which is set up by the entry of
particles of food into the air-passages, or by the secretion from the ulcerated
surfaces.

The duration of the disease enormously varies in different cases. The
longest case I have seen extended, between the appearance of a small nodule
on the anterior part of the right vocal cord and the end of life, to just four
and a half years. It is, however, very rare that patients survive more than
three years after the commencement of the disease, and often the total
duration, if the disease be allowed to proceed without let or hindrance, is
no more than from one to two years.

The initial stages of intrinsic malignant disease of the larynx are, of
course, somewhat different, if not the vocal cords themselves, but some other

LAKYNX, MALIGNANT DISEASE OF 379

part of the interior of the larynx, such as the ventricular bands or the sub-
glottic cavity, should be the original seat of the mischief. In such cases
for some considerable time no subjective symptoms may be produced at all.
The onset of such would arise when either the space for respiration is en-
croached upon or the action of the vocal cords interfered with. In such
cases the growth may have attained considerable dimensions previous to
causing any symptoms. The further development of the subjective symptoms
will in such cases, of course, be similar to the events sketched as character-
ising the later stages of malignant disease of the vocal cords.

The extrinsic variety, as a rule, draws the attention of the patient and
of his medical adviser at a much earlier time to the existence of grave
mischief than the intrinsic. When the new growth is situated on the
posterior surface of the cricoid plate, difficulty, and sometimes pain in
swallowing, together with secretion of at first purely frothy, later on some-
times slightly blood-stained phlegm, are the first signs of the disease. Soon
in most cases enlargement of the cervical lymphatic glands, at first under
the angle of the jaw, later on along the whole root of the neck, becomes
noticeable. This enlargement, according to the situation of the new growth,
is developed sometimes on one, sometimes on both sides. Occasionally it
attains such considerable dimensions already in early stages, when the
internal disease does not yet cause any troublesome symptoms, that the
original focus may be quite overlooked and the glandular disease supposed
to be primary. Several such instances have come under iny own notice.
As the growth in the variety now under consideration increases in size and
covers almost the whole plate of the cricoid cartilage, not only does dysphagia
increase, but also, owing to the mechanical destruction of the muscular
substance of the abductors of the vocal cords (the posterior crico-arytenoid
muscles), myopathic paralysis of these muscles and gradually increasing
narrowing of the glottis supervene, which often enough require early
tracheotomy. This class of cases is, owing to these circumstances, perhaps,
the most cruel variety of malignant disease of the larynx, the poor patient
hovering between starvation and suffocation. In still later stages symptoms
of perichondritis develop, and the final course is similar to that of the
intrinsic variety.

In cases in which the epiglottis is the primary seat of the mischief, at
first often simply some difficulty and pain in swallowing and change in the
timbre of the voice are noticed, the latter assuming a curiously " throaty "
thick character as the epiglottis is changed into a large tumour. The further
progress depends upon the direction in which the new growth progresses.
Usually it affects the root of the tongue and the lateral walls of the pharynx
and the oesophagus, when dysphagia will, of course, materially increase. Some-
times it descends into the larynx and causes respiratory difficulties in addition
to hoarseness and loss of voice. In a third variety it extends in both direc-
tions, when, of course, all the symptoms named will make their appearance
in combination. In this variety, too, the implication of the cervical
lymphatic glands may occur at so early a period that no suspicion is
entertained of the existence of the internal disease, and the glandular
tumour is considered to be primary.

In very rare cases a malignant tumour, particularly when starting from
the aryteno-epiglottidean fold, may be at first pedunculated, when the
symptoms, of course, would vary according to whether it falls into the larynx
or rests in the pyriform sinus, causing vocal disturbances and dyspnoea at
one, and inconvenience in deglutition at another time.

Finally, that extremely rare variety must be mentioned in which, from

380 LAEYNX, MALIGNANT DISEASE OF

the very first, the symptoms are so much those of perichondritis (pain,
difficulty in swallowing, vocal changes, febrility, etc.) that the existence of
malignant disease is hardly taken into consideration at all. I have quite
recently seen a case of that kind, in which the diagnosis of tuberculous
perichondritis had been made, and in which my diagnosis of malignant
disease was received rather incredulously. The further progress of the case,
however, fully established its correctness.

Diagnosis. — The diagnosis of malignant disease of the larynx in its
earliest stages often is very difficult, inasmuch as its appearances at its very
onset are so protean that it may easily be mistaken for various other
affections, the differential diagnosis from which will be treated
later on.

The very earliest sign as a rule is simple congestion of the parts which
afterwards become tumefied. This, of course, will be most manifest if the
disease starts from one of the vocal cords, and the unilateral character of
the congestion will at once draw the attention of the experienced observer
to the probability of impending graver mischief.

In other cases the disease, from the first, begins in the form of a diffuse tume-
faction. This tumefaction may occupy any part of the larynx, but its seats
of predilection are distinctly the vocal cords, and after them the ventricular
bands. In its further progress it may take either the form of a general
infiltration of the affected parts, in which all the preformed parts attacked
completely perish, or it may form a more definite tumour, appearing as a
rule as a somewhat globular, irregular, nodulated, sessile mass, the colour of
which may be either that of the surrounding mucous membrane, or some-
what more pale or more dusky-looking than the latter. Neither of the two
categories just described as a rule offers much difficulty in diagnosis when
the new growth has attained a certain size. Occasionally, however, par-
ticularly in cases of general tumefaction, matters are not so easy, and
mistakes may be committed, even by the most experienced observer. [See
further on the differential diagnosis between malignant disease, syphilis, and
tuberculosis.]

The really difficult cases, however, are those in which cancer or sarcoma
of the larynx make their appearance in the form of an apparently innocent
new growth. Malignant disease often enough shows itself first either in
the form of a somewhat nondescript tumour, or even completely simulates
the appearance of a papilloma or a fibroma. The similarity becomes even
more striking if, as in rare instances, the malignant new growth is
pedunculated. Should, as in a unique case observed by me, the papilloma-
tous appearance of a small epithelioma be additionally concealed by a large
blood-clot, which had formed round the papillomatous excrescences, the new
growth may be taken — as indeed it was in this case by several competent
observers- — for an angioma.

Whilst the difficulties in this class of cases are sometimes undoubtedly
very great, yet there are certain points which will help us in establishing
the differential diagnosis between benign and malignant growths of the
larynx.

First of all the age of the patient comes into question. Although
benign growths of the larynx may arise at any time of life, in fact from
intra-uterine existence up to the age of 80 or more, yet the earlier half
of life up to the age of 40 certainly is much more prone to such growths
than the later. On the other hand, as already stated, malignant growths,
though in rare cases they may arise at an early period of life, are infinitely
more frequent from the age of 40 upwards. Thus a growth, otherwise

LARYNX, MALIGNANT DISEASE OF 381

innocent-looking enough, the history of which shows that it had arisen after
the fortieth year, is a priori suspicious.

Secondly, a malignant new growth, even in its early stages, is often,
though not always, surrounded hy a zone of circumscribed dusky hyperemia,
which, particularly when the growth occupies the middle part of the vocal
cord, is in striking contrast to the brilliant white colour of the anterior and
posterior ends of the cord. It must, however, be emphasised that this hyper-
semia is not always present, and that its absence does not exclude
malignancy.

Thirdly, with regard to the differential diagnosis of malignant
neoplasms from individual forms of new growths, this is to be said : a
laryngeal cancer may at first look entirely like a papilloma, but a benign
papilloma shows a decided tendency to localise itself on the anterior parts
of the vocal cords, and it is therefore a priori suspicious if a papillomatous
growth, particularly in a person advanced in years, should be met with on
the posterior parts of the vocal cords, or worse still, in the inter-arytenoid
fold, where benign growths are hardly ever found.

The same applies to apparently innocent papillomata situated on the
epiglottis, or on the aryteno-epiglottidean folds. Again, the experienced
observer will at once think of the possibility of malignancy if he finds that
the individual projections of an otherwise apparently simple papilloma are
pointed instead of rounded, as those of an ordinary papilloma are, and this
suspicion will be increased if the colour of the new growth is snowy white
instead of pinkish as usual with laryngeal papillomata. In some such
cases the growth looks like a miniature snow-covered meadow. Needless to
say, the suspicion will be increased if several of the suspect features so far
mentioned are met with simultaneously, i.e. if a snowy meadow such as just
described is seen to occupy a position unusual for ordinary papillomata —
such as, for instance, the aryteno-epiglottidean fold — in the larynx of an
elderly person. Further, one's attention ought to be roused if one finds a
sort of papillomatous fringe occupying almost the entire length of one vocal
cord, whilst the other one is perfectly free.

A sign of grave diagnostic importance, is impairment of the mobility of
the vocal cord from which the new growth springs. The value of this sign,
to which I was the first to draw attention, has been repeatedly decried, and
my utterances on the subject have been curiously misunderstood by some
Continental authors. I wish, therefore, to declare as plainly as possible
that I neither believe such impairment of mobility to be present in every
case of early malignant disease of the vocal cords, nor that its absence in
any way militates against the disease being malignant. All I contend is
that if in the case of a doubtful growth springing from a vocal cord — and
not only when the growth is situated near the crico-arytenoid articulation,
but even in the anterior part of the vocal cord — an impairment of mobility,
i.e. some sluggishness of the movements of the affected cord, is observed, this
is a most valuable sign, pointing to the malignant nature of the affection.
This impairment of mobility is, of course, due to the infiltrating character
of the new growth, as against the mere surface-excrescence formed by a
benign neoplasm. It need, of course, not be present if the malignant new
growth should itself be more a superficial one, as, for instance, seen in
rodent ulcer, or if it should not yet have deeply penetrated into the tissues,
but if it be present, I have so often found it a sign of great value for the
early diagnosis of laryngeal malignant disease that no amount of contradic-
tion will shake my conviction.

It goes, however, without saying that this applies only to cases in which

382 LARYNX, MALIGNANT DISEASE OE

malignant disease appears at first in the form of a distinct tumour ; should
it take from its onset the form of a general infiltration and tumefaction, the
question of mobility of the vocal cord cannot be utilised for a differential
diagnosis, inasmuch as a syphilitic or tuberculous infiltration or a peri-
chondritic process or similar causes may also lead to impairment of the
mobility of the vocal cords, indistinguishable from that produced by
malignant infiltrating disease.

Only in very rare instances, and only in the early stages will there be
any danger of mistaking a malignant new growth for a fibroma. Some
doubt may occur when a red semi-globular sessile tumour makes its appear-
ance on the vocal cord of a middle-aged person. But whilst in fibroma the
semi -globular form is throughout maintained, and no impairment of
mobility of the cord nor any ulceration of the tumour itself occurs, even
when the growth has attained a very considerable size, in the further pro-
gress of malignant disease the tumour becomes mammillated, loses its semi-
globular form, becomes ulcerated, and interferes with the free mobility of
the cord itself. — In one of my cases even after microscopic examination of
the removed tumour the diagnosis remained doubtful between fibro-sar-
coma and soft continuous fibroma.

I am not aware that there is much danger of mistaking malignant
disease of the larynx for any other form of benign laryngeal neoplasms, my
own case, in which a suspected angioma turned out to be an epithelioma,
having so far remained unique.

It need hardly be said that in all cases in which the clinical examina-
tion alone does not suffice to establish the diagnosis, the aid of the microscope,
if possible, should be invoked. That is to say, a fragment of the growth
should be intralaryngeally removed, and subjected to searching microscopical
examination. No conclusion ought to be drawn from a single slide, unless
the appearances are absolutely characteristic of squamous-celled carcinoma.
The fragment removed should be examined throughout, and some of the
cuts should, if possible, be carried rectangularly to one another, so as to
diminish the possibility of mistakes. With all that, it ought to be re-
membered that growths are not necessarily homogeneous in their structure,
that the peripheral parts may contain no characteristic elements, and that
the more or less fortuitous character of intralaryngeal removal gives no
guarantee that really characteristic portions have been reached by the
laryngeal forceps with which the removal had been carried out.

Matters therefore stand thus : should the microscopic examination
definitely establish the histological characteristics of a malignant new
growth, well and good ; the diagnosis is settled. Should, however, the
microscopical evidence be simply negative, the inverse conclusion, viz. that
the growth was not malignant, is absolutely unpermissible, and the clinical
observer must continue to watch the progress of the suspected growth as
anxiously as he had done before the microscopical examination was made.
He has no right to throw the responsibility for an erroneous diagnosis upon
the microscopist, and must, if needs be, have the courage of his own opinions,
and proceed to radical operative interference even in the face of negative
microscopic evidence. Needless to say, the aid of the microscope is only
available if there be a projection sufficiently large to be intralaryngeally
removed. Often enough, in cases of general infiltration, this is not possible.

Having attained a certain size, which sometimes may be so considerable
that they practically fill the entire larynx, malignant new growths, whether
originally appearing in the form of a definite neoplasm or of a more general
infiltration, begin to break down in parts whilst they extend in the peri-

LABYNX, MALIGNANT DISEASE OF 383

phery. The time within which this breakdown begins to occur immensely
varies in individual cases. In most it will become apparent within a few
months from the onset of the disease ; in others, however, and I have seen
several such cases, the growth, having attained a certain size, remained
apparently stationary for a much longer time, the maximum I remember
being a year and a half, before ulceration occurred. From that period
onwards the laryngoscopic aspect usually is that of an irregular ulcerating
tumefaction, covered in part with grayish muco-pus, whilst in other parts
reddish fungating granulations may be seen to be springing up one day,
and to have practically disappeared the next. In still more advanced
stages, and particularly when the perichondrium has become involved, there
is often a very considerable amount of acute oedema to be seen round the
new growth, and this oedema may not very rarely completely obscure the
original disease. Often enough, between all these changes, it is extremely
difficult, if not impossible, to recognise the preformed parts of the larynx.

It will have been seen from the foregoing description that no uniform
picture must be expected in these cases ; practically every case shows some
individual differences.

When once the disease has advanced to that stage in which practically
the whole larynx has become involved, and changed into a partly ulcerating,
partly luxuriantly proliferating tumefaction, whilst at the same time the
glands underneath one or both jaws form very large, very hard, or even
externally ulcerating masses, there can be, as a rule, not much difficulty
about the differential diagnosis of malignant disease from other laryngeal
affections.

In the earlier stages, however, these difficulties sometimes are very con-
siderable, and indeed so great that even the most experienced observers are
not exempted from occasional diagnostic errors. Apart from benign neo-
plasms, the differential diagnosis from which has already been dealt with,
the affections with which malignant disease of the larynx is most likely to
be confounded are chronic laryngitis, syphilis, tuberculosis, lupus, peri-
chondritis, pachydermia laryngis, and paralysis.

The differential diagnosis from chronic laryngitis comes, of course, into
question only in the early stages of malignant disease, and is as a rule
facilitated (as already mentioned) by the fact that the congestion preceding
actual tumefaction in malignant disease is wm-lateral. Thus, if a vocal
cord should be the primary seat of the disease, the much congested colour of
the affected cord strikingly contrasts with the normally white one of the
other. At least one case, however, has come under my notice in which,
after a preliminary stage of apparently simple &i-lateral congestion of the
vocal cords, malignant disease of the larynx developed. In that case un-
usual complications occurred, inasmuch as, trusting to the non-dangerous
character of what appeared to be simple chronic catarrh of the larynx,
no objection had been medically raised to the patient's insuring his life
for a large sum shortly before the real character of the disease declared
itself. The possibility, remote though it be, of malignancy ought therefore
to be kept in view, if an apparently simple chronic laryngitis, even though
Z^-lateral, does not yield to the usual remedies.

With regard to syphilis the differential diagnosis often offers very con-
siderable difficulties. Of course, the previous history of the patient, the
coexistence of other syphilitic lesions in other parts of the body, or the
traces of old syphilitic disease in the form of scars, etc., will help in the
decision, but none of these are absolutely to be relied upon, as malignant
disease not rarely affects persons who have suffered from syphilis. Tertiary

384 LABYNX, MALIGNANT DISEASE OF

syphilis of the larynx manifests itself either by a distinct gummatous
tumour, or by a more general gummatous infiltration. The former, which,
as a rule, is red or yellow, usually solitary, occasionally multiple, and
surrounded by a zone of inflammation, as a rule breaks down very rapidly,
often within a few days, whilst a malignant ulcer requires, as a rule, weeks
for its development. When a gumma has broken down, a large, deep
crateriform ulcer results, whilst in a malignant ulcer tumefaction often
remains round the ulcer, and fresh thickening appears in the periphery.
The size of the carcinomatous ulcer usually is larger than that of a syphilitic,
and when once the boundaries of the larynx have been transgressed by
malignant disease, the infiltration of the cervical lymphatic glands as a
rule is much more considerable than that observed in syphilis. All these
signs, however, do not positively protect against occasional mistakes, and in
a good many cases the use of iodide of potassium will have to solve the
doubt. It will indeed be found a good rule to begin in every case of
malignant disease, whether there be any doubt as to the correctness of the
diagnosis or not, with the administration of iodide of potassium in large
doses for a week or a fortnight's time. The initial dose ought to be 10
grains three times a day, and this may be pushed to 30 grains or even
more three times daily. No conclusions as to the efficacy of that drug,
however, must be drawn from a mere subjective improvement. Often
enough, even in cases of cancer, iodide of potassium has a transitory bene-
ficial influence by resorbing the oedema surrounding the actual growth,
and the patient in such cases feels and swallows better, without the disease
being actually arrested. It is only from the occurrence of actual changes
for the better in the patient's larynx that a conclusion can be drawn as to
the syphilitic, as against the malignant nature of the ulcer.

In the great majority of cases the differential diagnosis of malignant
disease of the larynx from tuberculosis is much easier than that from
syphilis. The general constitutional symptoms, the almost always con-
comitant pulmonary affection, the patient's age, the bacteriological ex-
amination of the sputum, the characteristic pallor of the larynx, the pseudo-
cedematous infiltration of the mucous membrane over the epiglottis and
arytenoid cartilages, the slow development of the ulcers, their large number
and generally small size, the absence of considerable infiltration of the
glands in the neck — all these signs will, in the great majority of cases,
easily enough show the tuberculous nature of a laryngeal ulceration.

Still there are some cases in which the differential diagnosis is enor-
mously difficult. Thus a case of my own, observed in a gentleman, aged
over 50, in which an ulcer surrounded by cedematous tissue occupied the
posterior end of a vocal cord, whilst the rest of the larynx was perfectly
normal, and the lungs quite free, offered such diagnostic difficulties that an
exploratory thyrotomy had to be performed. Even after the larynx had
been opened, the nature of the disease remained doubtful, and only the
histological examination made by Mr. Shattock whilst the operation was
proceeding revealed the tuberculous nature of the mischief.

In another case just now under observation, more than one-half of the
epiglottis of a gentleman, aged 63, had been destroyed by ulceration, whilst
the remaining portion was changed into a shapeless red tumefaction, covered
with grayish muco-pus. From the sides of this, more ulceration extended
towards both the arytenoid and epiglottic folds. There were no signs
whatever, locally or constitutionally, of tuberculosis in the case, and every-
thing, except that there was no infiltration of the cervical lymphatic glands,
seemed to be in favour of malignant disease. The probatory removal,

LAKYNX, MALIGNANT DISEASE OF 385

however, of a piece of the stump of the epiglottis definitely established by
means of the microscope the presence of giant cells, and of very character-
istic tubercular tissue. The ulcerated portion was removed by sub-hyoid
pharyngotomy by Mr. Victor Horsley, and the patient is now making an
excellent recovery. Several cases are known in which the whole larynx
was removed, and this by good and competent observers, under the mistaken
impression that the disease was carcinomatous, whilst, in reality, the
disease was tuberculous. Still such cases are very rare, and in the
majority of cases the differential diagnosis between malignant disease and
tuberculosis seldom offers any serious difficulties. In connection with this
subject, it ought, however, to be borne in mind that undoubtedly occasion-
ally laryngeal carcinoma coexists with pulmonary tuberculosis, so that
even the discovery of bacilli in the sputum cannot be looked upon as an
infallible test.

Exceedingly rarely will there be any danger of mistaking cancer or
sarcoma of the larynx for lupus or vice versa. To begin with, primary
lupus of the larynx is very rare, and almost always there are con-
comitant signs in the nose, pharynx, and on the external integument.
Secondly, the particularly worm-eaten appearance of the lupoid ulcers is
very different from the deep and destructive ulcer, combined with a pro-
liferating tumefaction, which characterises the later stages of malignant
disease of the larynx. Extirpation of a fragment and microscopical
examination will, in doubtful cases, help to establish the diagnosis.

As repeatedly stated in previous paragraphs, the differential diagnosis
of malignant disease of the larynx, when appearing in the form of a general
infiltration, from a perichondritis due to various causes sometimes is very
difficult, and additionally, it must not be forgotten that in the later stages
of malignant disease of the larynx perichondritis forms one of the most
regular symptoms.

It has also been already stated that in some cases the symptoms of
perichondritis so entirely mask the original disease, that the differential
diagnosis as to the causes of the perichondritis may become a matter
of the greatest difficulty, and sometimes altogether impossible. In some
of these cases nothing but prolonged observation after the failure of a
course of iodide of potassium will settle the diagnosis ; a few cases have
been described in which, not only during life, but even at the post-mortem
examination, it was impossible to decide the actual nature of the case, and
in which only the microscopical examination of the diseased organ finally
settled the doubt. Under any circumstances, the observer will do well, if
he sees a case of otherwise inexplicable perichondritis of the larynx in a
grown-up person, with enormous tumefaction of the part, and (edematous
swelling of the mucous membrane, to remember, amongst other possibilities,
that he may have to do with cancer or sarcoma of the larynx. An explora-
tory thyrotomy may help to settle the doubt, but this means is of course
not one to be indiscriminately recommended.

Very considerable difficulties are sometimes experienced in making a
differential diagnosis between Virchow's pachydermia laryngis and malig-
nant disease of the larynx, if the latter should start from the neighbour-
hood of the vocal process of the arytenoid cartilage. The laryngoscopic
appearances of both diseases are sometimes extraordinarily similar to one
another, and even the most experienced observer may, in cases in which the
affection is unilateral, and the tumefaction at the posterior end of the
vocal cord much developed, be very doubtful for a while as to what he has
to deal with. Under these circumstances I have always found the
VOL. vi 25

386 LAEYNX, MALIGNANT DISEASE OF

question of the mobility of the affected cord a most valuable aid in the
diagnosis.

Pachydermia, in my experience, never causes, however much the tume-
faction may be developed, impairment of the mobility, whilst malignant
disease, when originating in that situation, usually leads, from its neigh-
bourhood to the crico-arytenoid articulation, to a distinct sluggishness of
the affected vocal cord, even if the tumour be still small. I am well aware
that cases of pachydermia have been reported in which an impairment of
the mobility of the affected vocal cord was stated to have been present, but
I have, in a rather large experience of that disease, never seen such a case,
and can only recommend to look upon the question of the mobility of the
affected vocal cord as a very valuable differential diagnostic sign. In later
stages, i.e. when a second pachydermia has developed on the corresponding
part of the opposite vocal process, and when its most prominent part fits
into the cup gradually arising in the middle of the original pachydermia,
the difficulty of a differential diagnosis is but small, but it ought not to be
left altogether out of consideration that in very rare cases, such as I have
once described together with Mr. Shattock, a secondary carcinoma oy
contact may develop on the opposite vocal cord.1

The differential diagnosis between malignant disease of the larynx and
various forms of paralysis will in very rare cases only come into question.
If so, the diagnosis usually, for a time at any rate, is extremely difficult.
Thus, I have seen two cases in which the appearances were completely those
of bilateral paralysis of the glottis-openers, the vocal cords lying close to
one another in the middle line of the larynx. The subsequent course, how-
ever, proved that this appearance was due to subglottic malignant growth,
in one case to an epithelioma, in another to sarcoma.

Finally, I may mention that, from my own personal experience, I do
not think it possible to make a clinical and differential diagnosis between
sarcoma and carcinoma of the larynx. I know perfectly well that directions
describing different appearances of these two forms of growth may be found
in almost all handbooks of laryngology, but I confess that I personally have
never been able, from mere laryngoscopic examination, to distinguish between
them clinically, either in their early or more advanced stages, and that in
all my own cases the differential diagnosis has been arrived at by means
of microscopic examination, either of fragments intralaryngeally removed
before radical operation, or of the entire growth after this had been
performed.

Prognosis. — "Whilst there is unfortunately even now a but too uni-
versal belief that malignant disease of the larynx is necessarily a fatal
disease, the progress made in both the diagnosis and the operative treat-
ment of carcinoma and sarcoma of the larynx in the course of the last fifteen
years is such that, in reality, matters are very different. As a matter of
fact, the prognosis of malignant disease of the larynx varies enormously in
individual cases according to (1) the original starting-point of the growth ;
(2) the period at which the patient comes under observation ; (3) his general
health. From personal experience, I have no hesitation in stating that if
an intrinsic laryngeal cancer in a middle-aged or, at any rate, not too old
and otherwise healthy person, comes under observation at an early stage,
and if the patient agrees to radical operation without delay, the prognosis is
equally good, if not better, than in any other form of malignant disease in
any other part of the body. I make this statement on the strength of the

1 "Three Cases of Malignant Disease of the Air-Passages," Transactions of the Pathological
Society of London, 1888. Case 2.

LAKYNX, MALIGNANT DISEASE OF 387

fact that my own percentage, not merely of successful operations, but of
lasting cures in this class of cases, at present amounts to 83'3 per cent.
The prognosis, therefore, in this variety can unhesitatingly be pronounced
to be very favourable.

On the other hand, if the patient, even though the affection originally
belonged to the intrinsic variety, comes under observation at a time when
the disease has become very extensive, when the cervical lymphatics have
become involved, when his general health has already begun to suffer, the
prognosis, needless to say, is, even now, a very grave one. The same applies,
to an even higher degree, when the growth is primarily extrinsic, and
particularly when it starts from the posterior surface of the cricoid plate.
It is true that the progress of surgery has enabled us to save a good many
even of such cases by more perfect methods of operation ; still this can
only be done by means of very serious and mutilating operative interfer-
ence, and the risk of recurrence in this class of cases is extremely great. It
need hardly be said that the prognosis will greatly depend also upon the
age and general health of the patient, very old persons, and such afflicted
with albuminuria and chronic affections of the respiratory passages, being
a priori not nearly such suitable subjects for the operation as younger and
generally healthy individuals. The general outcome of the foregoing
observations is this, that in every case of malignant disease of the larynx
one will have to strictly individualise with regard to the prognosis of life
and the chance of operation.

Treatment. — The treatment of malignant disease of the larynx at the
present moment can be only of a surgical character, and it has already
repeatedly been stated that its prospects nowadays are much better than
they used to be only a few years ago. There are, however, two dangers
with regard to the selection of the method of surgical interference, which
have become developed during the last few years, and against which a note
of serious warning ought to be sounded. The aim of the practitioner in malig-
nant disease of the larynx ought to be to recognise the malady whilst it is
still a purely local affection, and to remove it in that stage so thoroughly as
to preclude, if possible, the danger of recurrence. Two extremes ought to be
equally avoided, viz. doing too little, and doing too much. The first of these
two extremes is, in my opinion, represented by the intralaryngeal method,
which has of late years been warmly and repeatedly recommended by
German authorities whose names justly command respect. But the selec-
tion of this method in cases of malignant disease appears to my mind to
militate against the very nature of cancer and sarcoma. It is their
characteristic that they do not merely grow from the surface, but that they
infiltrate the mother soil from which they spring. Quite in accordance
with this is the fact, which I have stated years ago, and which since then I
have over and over again had the opportunity of corroborating, viz. that
when the larynx is opened in a case of malignant disease, it is almost
always found that the infiltration is much more extensive than one would
have thought from laryngoscopic examination. Now, whilst the intra-
laryngeal method is excellently suited for the removal of excrescences from
the surface, it does not give the least guarantee for a really radical and
complete removal of infiltrated deeper tissues, and there is not the least
certainty that even if all that appears suspect has been removed, the disease
should not, all the while, progress without let or hindrance in these deeper
structures which have not been reached by the intralaryngeal operation,
without, for a considerable time, manifesting its presence in these tissues.
The patient must, therefore, keep himself under constant observation for a

388 LAEYNX, MALIGNANT DISEASE OF

very long time, and even such observation, if the disease be extending into
the subglottic cavity, does not offer any guarantee against dangerous
progress of the affection in that laryngoscopically only in part visible region.
Thus, the proper moment for more radical operation may ultimately become
irretrievably lost. Additionally, when the intralaryngeal method has been
employed, the risk of constantly irritating by incomplete operation the
affected part, and thereby producing a quicker rate of progress of the disease,
is certainly more than theoretical, and ought to be taken into serious con-
sideration. I am fully aware that a number of cases have been cured by
intralaryngeal operation, and do not in the least doubt their actuality, but
I consider the selection of the intralaryngeal method for that class of cases
none the less as dangerous and altogether undesirable.

Equally little in the interest of the patient appears to me the other
extreme, which has met with some acceptance in Germany, viz. excision
of the whole larynx as soon as the diagnosis of malignant disease of that
part has been made. If the disease could not otherwise be eradicated
than by such heroic measures, matters would be different, but when, in a
large number of early cases, a much less mutilating interference has been
positively demonstrated to suffice for effecting a lasting cure, it appears to
me hardly defensible to deprive the patient of an important organ, and of
the use of his voice, not to speak of his being made a subject, half of pity,
half of repulsion for the rest of his life, on account of the theoretical
argument that total extirpation gave better chances against recurrence
than partial extirpation or simple thyrotomy with removal of the soft parts.
So long as the last-named operation was still on its trial in cases of this
sort, such an argumentation in favour of total extirpation had some show
of reason, but now that the experience of the last ten years has demonstrated
by actual facts that all that is necessary can be obtained by means of so
infinitely simpler, less mutilating, and less dangerous an operation, as thyro-
tomy is in comparison to total extirpation, it seems time that the latter
method should be reserved for such cases only in which it is indispensable,
and that in initial cases of intrinsic cancer or sarcoma thyrotomy should be
generally awarded that position which, in the experience of those who have
methodically practised it during the last ten years, it fully deserves.

As to the operative methods which ought to be selected in any in-
dividual case, they must depend entirely upon the primary situation of the
new growth and on the stage in which the case comes under observation.
In cases of intrinsic malignant disease, particularly when it is limited to the
vocal cords, or to their neighbourhood, there can nowadays be no doubt
that thyrotomy is the proper procedure. Personal experience, extending
over twelve years, has convinced me that if, after the performance of
tracheotomy, and the protection of the trachea by means of Halm's sponge-
canula, and of additional sponges, if necessary, against the entry of blood
into the lower air-passages during the operation, the larynx be opened, the
two wings of the thyroid held asunder, and the new growth, with an area of
healthy tissue around every part of its circumference, be (after previous
cocainisation of the part) thoroughly excised, and the basis of the removed
part thoroughly scraped with Volkmann's sharp spoon, not only is the
operation reduced to a minimum of risk, but also the chances of absence of
recurrence, if the disease should have been still limited, are excellent. (See
under Prognosis.)

The prospects of the voice after the performance of thyrotomy, if one
vocal cord only should have been removed, are also surprisingly good. In
the great majority of cases a cicatricial ridge forms in the situation just

LAEYNX, MALIGNANT DISEASE OF 389

corresponding to the former place of the removed vocal cord, and on the
healthy cord joining this ridge in phonation, a loud and serviceable voice is
produced, which sometimes has a hoarse timbre, but in not a few cases is
almost normal. Thus one of my patients, a clergyman, from whom eight
years ago the whole of the left vocal cord and the front part of the left
arytenoid cartilage were removed on account of a fibro- sarcoma, now
regularly preaches in a church holding 400 people. To obtain good results,
however, it cannot be too strongly insisted upon that no undue senti-
mentality with regard to the subsequent preservation of the voice should
be allowed to prevail over considerations of safety with regard to recurrence ;
and it is absolutely necessary to perform the operation everywhere in the
healthy tissue surrounding the growth, and not too near the latter. For
further particulars with regard to the technique of the operation I would
refer to my various contributions on the subject.1

A further point in connection with the question of the selection of
thyrotomy in this class of cases is this, that under no circumstances should
the operator approach the operation with the fixed intention of performing
thyrotomy and nothing else. But too frequently one finds after opening
the larynx that the disease is more advanced than one had thought after
laryngoscopic examination, and that mere removal of the soft parts under
such circumstances was not likely to give a sufficient guarantee against
recurrence. In such circumstances resection of parts of cartilages, or even
partial extirpation of the larynx, ought to be proceeded with. If the disease
should only come under observation at a more advanced stage, if there be
already signs of perichondritis, or if there be any doubt as to whether the
cartilage itself had become affected, partial extirpation will of course take
the place of mere thyrotomy. In still more advanced stages in which both
sides of the larynx are affected, or in which the disease, unfortunately, be
situated on the posterior wall of the larynx, nothing short of total extirpa-
tion of the organ, combined, if necessary, with removal of the already
affected cervical lymphatic glands, may become imperative. In these cases
the principle of commencing the operation by cutting the trachea horizontally
and sewing the lower end into the edges of the skin-wound has recently led
to a very considerable diminution of the danger of sepsis after the operation,
and to a much greater saving of life. But it need not be said that total
extirpation means a grave mutilation, that an artificial larynx is but a sorry
substitute, which additionally can apparently be worn at length by a few
patients only, and that in those cases in which the lower end of the trachea
has been sewn into the external wound a weak, toneless, whispering sound,
produced in the pharynx, is the best that can be expected unless an artificial
larynx, such as Professor Grluck's new contrivance, be always used. Still,
life is valued so highly by many patients, and the surgical progress in
treating even much advanced cases of laryngeal cancer, complicated by
infiltration of the cervical lymphatic glands, has been of late years so great,
that one ought not to dissuade the patient from undergoing the operation,
but leave the decision to them.

In cases, finally, in which the disease starts from the epiglottis or an
aryteno-epiglottidean fold supra-hyoid pharyngotomy would seem to be the
least serious operation, and at the same time to completely suffice to remove

1 "On the Eesults of Radical Operation for Malignant Disease of the Larynx," Lancet,
December 15, 22, 29, 1894; "Zur Frage der Radikaloperation bei bosartigen Kehlkopfneu-
bildungen mit besonderer Beriicksichtigung der Thyreotomie, " Archiv/iir Laryngologie, Band
vi. Heft 3 ; "Die Thyreotomie bei bosartigen Kehlkopfneubildungen," Therapie der Gegen-
wart, April 1899; " Einige Bemerkungen zu der neuen Sendziak'schen Statistik iiber die
operative Behandlung des Larynxkrebses," Monatschrift filr Ohrenheilkuncle, No. II. 1899.

390

LARYNX, NEUROSES OF

the growth in toto. This operation has not hitherto been extensively
practised, probably because the cases suitable for it are, on the whole, rare,
and in those cases in which it has been performed a curious fatality has
followed ; but it may fairly be hoped that by perseverence in it better
results will be obtained in the near future.

Finally, in such cases in which the patient either refuses to undergo a
radical operation or in which he comes under observation too late for such to
be recommended, or in cases in which the disease is situated on the oesophageal
aspect of the cricoid cartilage, extending from there downwards, so that not
only total extirpation of the larynx, but also resection of a large part of the
oesophagus, would be required — a class of cases, moreover, almost always
complicated by early and very considerable implication of the cervical
lymphatic glands — palliative measures will have to be resorted to to
maintain as long as possible the patient's general health and strength.
Should there be much difficulty in respiration, tracheotomy ought to be
performed at not too late a period. The relief given by that operation is
much greater if it be not postponed till the very last, when, often enough,
its first result is an acute bronchial catarrh, which takes away still more of
the patient's strength. Tracheotomy in these cases ought to be performed
low down, so that if possible the tracheotomy wound may not be reached by
the disease in its further progress. Often enough, considerable subjective
improvement will be noticeable if the patient permits of the tracheotomy
being performed in time. Should there be great pain from the ulcerating
surfaces, cocaine in the form of a spray, or orthoform by means of insuffla-
tions, will do palliative service, and in the more advanced stages injections
of morphia may have to be resorted to. Should the growth ulcerate externally
applications of bismuth in powder form are of value.

The diet, of course, particularly if the swallowing be painful, should
be of a soft, senii- solid, bland kind, and finally, feeding either through
an oesophageal tube or by means of nutrient enemata may be required.

LITERATURE. — The literature on malignant disease of the larynx is enormous. In addi-
tion to the papers mentioned in the above article itself a few of the more important modern
contributions only will be given. — H. T. Butlin. The Operative Surgery of Malignant Disease,
2nd edition, 1900, chap. xvi. "The Larynx." — F. Semon. Die Frage des Ueberganges gutartiger
Kchlkopfgesehwiilste in bosartige, etc. 1889, Berlin, Aug. Hirschvald. — 0. Chiari. "Beitrage
zur Diagnose und Therapie des Larynxkrebses," Archiv f. Laryngologie, Bd. viii. 1898. — Th.
Gltjck. "Die chirurgische Behandlung der malign en Kehlkopfgeschwulste, " Berliner Mill.
Wochensehrift, Nos. 43-45, 1897. — Johann Sendziak. Die bbsartigen Geschiviilste des Kehlkopfs
und Hire Radicalbehandlung, Wiesbaden, J. F. Bergmann, 1897. — E. Schmiegelow. "Cancer
du larynx, diagnostique et traitement," Annales des maladies de Voreille et du larynx, April
1897.

Neuroses of Larynx

Innervation of the Larynx

391

Sensory Neuroses .

393

Ancesthesia . . . .

393

Hyperesthesia
Motor Neuroses —

393

Inspiratory Spasm in Adults .
Nervous Laryngeal Cough
Phonic Sjmsm

393
394
365

Laryngeal Vertigo

Paralysis op the Vocal Cords — ■

Lesions of Superior Laryngeal

Lesions of Recurrent Laryngeal

The Diagnosis of Laryngeal

Paralysis ....

Hypertrophy of the Lingual

Tonsil

395

396
396

398

401

See also " Laryngismus Stridulus," p. 408.

The larynx subserves two main functions, viz. phonation and respiration.
Phonation is a volitional act, and the nerve centres for this function are

LARYNX, NEUROSES OF 391

mainly represented in the cerebral cortex. There are, however, phonetic
acts which are mainly reflex in character, viz. coughing, sighing, hiccough,
etc., and these, like other somatic reflexes, are mainly represented in the
bulbar centres. Respiration is essentially a reflex act, and therefore the
respiratory centre is mainly represented in the bulb, and the bulbar centres
(in the dog) have been shown by Horsley and Semon to suffice for respira-
tion after complete removal of the cerebral hemispheres. For these two
essentially distinct functions there are two separate sets of muscles, viz.
the adductors of the vocal cords for phonation, and the abductors or glottis-
openers for respiration.

Innervation of the Larynx. — The larynx receives its nerve-supply
from the superior and recurrent laryngeal branches of the vagus nerve on
either side ; the former supplies sensation to the whole of the mucous mem-
brane of the larynx, and is also the motor nerve to the crico-thyroid muscle.
The recurrent laryngeal nerve contains no sensory fibres, except perhaps
muscle-sense fibres, and is the motor nerve to all the intrinsic laryngeal
muscles except the crico-thyroid. It is probable that the interarytenoideus
muscle receives motor twigs from both the superior and inferior laryngeal
nerves of both sides.

Vaso-motor and secretory nerve fibres are supplied to the whole of the
laryngeal mucous membrane by the superior laryngeal nerves.

Without entering on the debated ground as to whether the nuclear
centres of the motor fibres of the laryngeal branches of the vagus nerve in
the medulla are anatomically associated with the spinal accessory nucleus,
or with the common glosso- pharyngeal and vagus nucleus, the nucleus
ambiguus, it must be admitted that the weight of evidence is in favour of
the latter view. In other words, the lower portion of the nucleus ambiguus
corresponding to the accessory nerve roots emerging from the bulb, which
may be conveniently distinguished by the term vago-accessory, are in this
sense the lower roots of the vagus. No confusion will arise from the em-
ployment of the term vago-accessory to the motor roots and the motor
nuclei of the motor nerve fibres to the larynx which are contained in the
vagus nerves. In addition to this ventral large-celled nucleus or nucleus
ambiguus, there is a dorsal small -celled nucleus, the so-called combined
nucleus which lies external to the nucleus of the hypoglossal nerve in the
medulla ; this is a motor root, and it has been suggested that it is a nucleus
for unstriped muscle. The sensory nuclei of the vagus are contained in its
root and trunk ganglia from which the axones enter the bulb and pass to the
nuclei in the gelatinous substance in the neighbourhood of the fasciculus
solitarius.

The cortical laryngeal centres have been located in the anterior portion
of the lower extremity of the ascending frontal convolution, thus on the
left side forming a part of Broca's speech centre. Thence their fibres pass
down through corona radiata and internal capsule to reach the medulla
oblongata.

Semon and Horsley have demonstrated in the cat, and Risien Russell in
the dog also, that there are separate cortical centres for abduction and
adduction of the vocal cords, and, moreover, these observers proved that both
in the cortex and in the medulla each centre is bilateral in action. Hence
it follows (1) that destruction of the centres on one side cannot give rise
to paralysis of one vocal cord, since the remaining centre continues to act
equally on both vocal cords ; (2) that irritation of one centre, either in the
cortex or in the medulla, may cause bilateral spasm of the vocal cords.
As will be seen these facts are of considerable clinical importance, for —

392 LARYNX, NEUROSES OF

(1) In unilateral hemiplegia, e.g. right -sided hemiplegia with motor
aphasia, the movements of the vocal cords are unimpaired.

(2) Paralysis of one vocal cord cannot be due to a cortical lesion (unless
it involves both cerebral hemispheres).

The motor fibres for each set of muscles, though running together, are
separable into two distinct strands of fibres, both in the recurrent nerve
(Russell) and in the internal capsule (Semon and Horsley).

Semon's Law. — It is a remarkable fact of great clinical interest, demon-
strated by Sir Felix Semon, that " there exists an actual difference in the bio-
logical composition of the laryngeal muscles and nerve-endings," rendering the
abductors more prone to be affected by conditions resulting in paresis and
atrophy than the adductors ; " whilst the fact that also in central (bulbar)
organic affections, such as tabes, the cell groups of the abductors succumb
earlier than those of the adductors, points to the probability that similar
differentiations exist in the nerve nuclei themselves." Thus in all progressive
organic lesions of the centres or trunks of the motor nerves of the larynx,
the more vulnerable abductor muscles are first involved, and, unless the
lesion is so gross as to cause total paralysis of the laryngeal nerves from the
outset, the abductors are for a time alone affected. This vulnerability of
the abductors, as compared with the adductors, is known as Semon's law :
the order in which the muscles are involved being (1) the abductors or
crico-arytenoidei postici (posticus paralysis) ; (2) the thyro-arytenoidei in-
terni ; and (3) lastly, the adductors or crico-arytenoidei laterales.

The motor fibres to the larynx are contained in the vagus nerve as it
passes out of the skull through the jugular foramen, whence it descends
within the sheath of the carotid vessels, passing through the neck to the
thorax

In the thorax the course of the nerve becomes different on the two sides
of the neck. On the left side it enters the chest between the common
carotid and subclavian arteries, and crosses the arch of the aorta, where it
gives off the left recurrent nerve which winds backwards round the aorta,
and then ascends to the side of the trachea to the groove between the
trachea and oesophagus, and enters the larynx behind the articulation of
the inferior cornu of the thyroid cartilage with the cricoid cartilage. On
the right side the vagus nerve passes across the subclavian artery, where it
gives off the right recurrent branch, which winds backwards beneath this
vessel, and, lying on the apex of the right lung, ascends obliquely to the
side of the trachea, whence its course to the larynx is the same as on the
left side. The superior laryngeal nerve on either side arises from the in-
ferior ganglion of the vagus, whence it descends by the side of the pharynx
behind 5the internal carotid artery, and then, after giving off the external
laryngeal branch to the crico-thyroid muscle, pierces the crico-thyroid mem-
brane, and enters the larynx with the superior laryngeal artery.

Obviously in this long course the motor fibres to the larynx may be
irritated or compressed by a large variety of pathological conditions, to
which attention will be drawn farther on. But it will also be noted that
the vagus nerves as far as the inferior ganglion, and beyond that point, the
superior laryngeal nerves, contain both afferent and efferent nerve fibres to
the larynx, while the recurrent laryngeal nerve is a purely motor nerve.
It follows that irritation or compression of one vagus (or of the superior
laryngeal nerve) may have a bilateral effect, the peripheral irritation being
conducted to the bilateral medullary centre, while irritation or compression
of the purely motor recurrent nerve on either side can only affect the
corresponding vocal cord. These differences afford an explanation of the

LARYNX, NEUROSES OF 393

alternating bilateral spasm and unilateral abductor paralysis sometimes
observed in aneurysm of the aortic arch.

SENSOEY NEUROSES

The neuroses of sensation in the larynx comprise anaesthesia, hyper-
esthesia, and paresthesia.

Anaesthesia may be partial or complete, and may involve the whole of
the laryngeal mucous membrane, or be confined to the epiglottis or the
supraglottic portion, and further may be unilateral or bilateral. Anes-
thesia may be caused by peripheral lesions, e.g. injury to the nerve, diph-
theria, etc., or to central lesions, as in bulbar paralysis, tabes dorsalis,
epilepsy, and is not infrequently due to hysteria. It is generally associated
with motor paralysis of various laryngeal muscles.

The symptoms consist mainly in the tendency for food to enter the
larynx and produce attacks of choking. It is especially dangerous when
the anesthesia is complete and involves the subglottic region, as then no
laryngeal spasm and cough result, so that the food particles are prone to
pass into the lower respiratory tract and set up " foreign-body " pneumonia.

The diagnosis can only be made with certainty after touching the laryn-
geal surface with a probe, when the defective sensation can readily be
detected.

Hyperesthesia. — A variety of sensations described as rawness, constric-
tion, or tickling, are encountered in anemic, hysterical, or hypochondriacal
patients. Such sensations may be caused by reflex irritations from enlarged
faucial or lingual tonsils, but the purely neurotic cases are usually associated
with other vague sensations in the region of the pharynx, local causes, from
the sensations complained of being entirely absent. Of course sensations
of pain or pricking are met with in many organic diseases of the larynx,
but such cases do not come under the designation " neuroses."

The diagnosis is to be made by the exclusion of organic causes for the
sensations and the concurrent symptoms pointing to a neurotic tempera-
ment which are very seldom wanting. The coexistence of laryngeal
paralysis involving the abductor muscles would strongly suggest some
organic lesion as the real cause of the symptoms of hyperesthesia.

Treatment of Sensory Neuroses. — The exhibition of nerve tonics and the
adoption of general hygienic measures is indicated in all these neuroses.
When anesthesia is due to diphtheria local faradisation and the treatment
of any organic affection will demand attention. When laryngeal anes-
thesia results in the escape of food into the larynx it may become necessary
to feed the patient by means of a stomach-tube or by rectal enemata.

MOTOR NEUROSES

The clinical affections comprised in the group of laryngeal neuroses may
be conveniently described under three headings : (i.) Spasmodic affections ;
(ii.) Neuroses of incoordination ; (hi.) Paralytic affections.

SPASMODIC AFFECTIONS OF THE LARYNX
A. Respiratoky Glottic Spasm

1. Laryngismus stridulus, or "false croup" and Laryngeal stridor, see
p. 406 et seq.

2. Inspiratory Spasm in Adults. — Laryngismus stridulus is essentially

394 LAEYNX, NEUEOSES OE

an affection of childhood and dependent on conditions which are not
observed in adult life ; the same may be said of the affection congenital
laryngeal stridor, which, though not, strictly speaking, a neurosis of the
larynx, closely resembles in its clinical aspects laryngismus stridulus.
In adult life spasm of the glottic sphincters is usually a reflex phenomenon
dependent on morbid conditions in the larynx or in other parts of the
respiratory tract, e.g. the presence of growths, catarrhal, tubercular, or other
affections in the larynx itself, or the pressure of neoplasms, aneurysms on
the laryngeal motor nerves. It may be caused by an elongated uvula,
adenoid hypertrophy at the base of the tongue, or it may be set up by the
excessive irritability resulting in gouty or rheumatic laryngitis.

Functional inspiratory spasm, the so-called " hysterical spasm," is liable
to arise in hysterical females from slight causes, such as emotional disturb-
ance ; it is generally incomplete and transient, but has been known to be
prolonged till consciousness is lost. Eunctional spasm in the larynx is
sometimes associated with pharyngeal or oesophageal spasm.

Certain organic affections of the motor nerve centres are liable to be
associated with laryngeal spasm, e.g. tabes dorsalis with laryngeal crises,
hydrophobia, tetany.

Diagnosis. — It is important to recognise the existence of any organic
disease in patients complaining of laryngeal spasm. Paroxysmal glottic
spasm, accompanied by a peculiar and characteristic brassy cough, is often
one of the earliest indications of intra-thoracic aneurysm ; laryngeal crises in
tabes dorsalis are usually associated with abductor paralysis of one or both
vocal cords, while bulbar crises may follow diphtheria. Further examina-
tion of the patient would reveal the existence of such sources of laryngeal
spasm. Hysterical spasm may generally be detected by directing the
patient to phonate during laryngoscopic examination, the prolonged utter-
ance of a note being usually followed by reflex abduction of the cords as
soon as the breath is exhausted. Indications of the gouty diathesis, or of
local abnormalities in the larynx, may be held responsible for the occurrence
of the laryngeal spasm only after the elimination of the graver conditions
to which allusion has been made.

Nervous Laryngeal Cough

The " barking cough of puberty," as it was termed by Sir Andrew Clark,
or laryngeal chorea, is really one of the convulsive tics, and is not in any
way associated with voluntary laryngeal function. It occurs in young
persons, both males and females, about the time of puberty. The cough is
a single, peculiar, loud, harsh bark ; sudden in onset, persisting at irregular
intervals throughout the day, but generally ceasing during sleep. The
voice is not affected.

The absence of expectoration or of any lung symptoms, coupled with
the peculiar character of the cough, renders the diagnosis easy.

Spasmodic Laryngeal Cry. — The so-called " hydrocephalic cry," believed
by Trousseau to be characteristic of cerebral meningitis, may rarely occur in
various conditions associated with cortical irritability, and may be accom-
panied by spasmodic contraction of other muscles.

The treatment of respiratory glottic spasm consists almost entirely in
the general treatment of the underlying conditions which have been
referred to. For the laryngeal spasms of tabes dorsalis the inhalation of
nitrite of amyl may give relief, and sometimes the attacks, if slight, may be
kept off by spraying cocaine into the larynx. It is important in all affec-

LAEYNX, NEUKOSES OF 395

tions attended with laryngeal spasm to avoid as far as possible everything
which may cause laryngeal irritation, such as smoking, etc.

Phonatory Glottic Spasm

Phonic Spasm, in which spasm of the adductors and tension of the vocal
cords occurs only during vocalisation, is a somewhat rare affection usually
met with in professional voice -users. It is essentially an occupation
neurosis, and is rarely seen except in those of a highly nervous tempera-
ment. In some cases ordinary conversation is not interfered with, the
impairment or loss of voice only occurring during attempts at public
speaking or singing.

In its earliest manifestation there is weakness or loss of voice commen-
cing soon after the patient begins to read, speak, or sing. In course of time
the difficulty increases until every attempt to use his voice only results in
futile endeavours to force a current of air through the spasmodically closed
glottis, — the glottic closure, however, ceasing as soon as he desists from his
attempts to phonate.

The treatment of this affection is often disappointing, as is the case with
all occupational neuroses. Any faulty method of producing the voice
should be corrected, and the patient should abstain for a time from all the
conditions associated with the occurrence of the spasm. Prolonged rest
and the exhibition of nerve tonics will sometimes result in curing the less
pronounced cases.

Laryngeal Vertigo. — An affection characterised by a series of coughs,
followed by glottic spasm, and transient, partial, or complete loss of con-
sciousness, which is not followed by stupor or other indications of epilepsy,
was originally described by Charcot as "laryngeal vertigo." The term
is unfortunate, inasmuch as true vertigo is hardly ever present in this
disease.

The precise nature of the attack has not been definitely settled ; it has
been regarded by different observers as a form of epilepsy (petit mat), as
due to syncope, or as the result of forced expiration with a closed glottis.
M'Bride has put forward the last-named theory, and Weber has shown that
a somewhat similar condition can be produced voluntarily by forced expira-
tions with a closed glottis. In support of the " petit mal " theory, it may be
said that the sudden partial or complete loss of consciousness with rapid,
complete recovery is sometimes attended with indrawing of the thumb on
the palms, or with epilepsy, and that the attacks are often indistinguishable
from petit mal. Getschell, who collected reports of forty-one cases, con-
sidered that the average age of the patients was opposed both to the
" epileptic " and the " forced expiration " theories. Of the forty-one cases,
loss of consciousness during bad attacks was reported in thirty-two cases,
and falls in twenty-six. True vertigo was mentioned in one case only ;_ in
five, slight mental confusion and dizziness in sight was noted. Bronchitis
is present in some cases. In one case coming under my own observation
the attacks were always the result of pressure over the laryngotracheal
region. A few short coughs were rapidly followed (not suddenly) by partial
loss of consciousness, which became complete only after an appreciable
period, and then persisted for several minutes. The patient, a boy, was
certain that his respiratory embarrassment was expiratory only, not
inspiratory.

Treatment. — The patient is always of the nervous temperament, but is
generally healthy. Any catarrhal condition of the respiratory tract should

396 LAEYNX, NEUEOSES OF

be corrected by appropriate treatment. General hygienic measures and the
administration of bromides may prove beneficial. In my own case the
attacks were cut short by the application of a sponge with very hot water
to the throat externally. The inhalation of nitrite of amyl would probably
have relieved the glottic spasm, but I have no knowledge of any case
of the kind in which it has been tried. The patient usually recovers
consciousness so rapidly without any assistance that it is only in exceptional
attacks that any treatment during an attack could be required.

Paralysis of the Vocal Cords

Vocal cord paralysis obtains a far-reaching clinical significance, not alone
on account of the inconvenience or danger that may be caused from the
resulting loss of voice or urgent dyspnoea that may result, but also on account
of the valuable aid that such paralysis may afford in the diagnosis of many
diseases in other regions ; indeed, a laryngoscopic examination revealing a
vocal cord paralysis may afford the one and only definite physical sign
pointing to the existence of some grave organic disease such as tabes dorsalis,
aortic aneurysm, etc. The subject will be much simplified by grouping the
varieties of laryngeal paralysis together in discussing their etiology and
clinical significance. The section will therefore be considered in the
following order : —

I. The signs and symptoms of the various forms of paralysis resulting
from implication (a) of the superior, and (6) the recurrent laryngeal nerves.

II. The etiology and pathology of laryngeal paralysis.

III. The treatment of the various forms of laryngeal paralysis.

IV. The clinical significance of laryngeal paralysis.

Paralysis of the Muscle supplied by the Superior Laryngeal
Nerve. — The only muscle supplied by the superior laryngeal nerve is the
crico-thyroid, the action of which is to assist in rendering tense the corre-
sponding vocal cord. Paralysis of this muscle alone is rare, but it obviously
must occur in association with the anaesthesia of the larynx resulting from
section of the superior laryngeal nerve, and has also been described as result-
ing from cold, diphtheria, pressure of growths, etc.

When the crico-thyroid muscle is paralysed, the vocal cord presents a
wavy outline, bulges up in the centre in forced expiration, and is depressed
on inspiration, these phenomena being due to the defective tension of the
cord.

The treatment is essentially the same as for laryngeal anaesthesia when
that is present, and which is due to implication of this nerve. For weakness
or paralysis of the muscle external faradisation is sometimes called for.

Paralysis of the Muscles supplied to the Eecurrent Laryngeal
Nerves. — As stated above in progressive organic lesions involving the
motor nerves of the larynx, the muscles succumb in the following order : —
Abductors of the cords, internal tensors, adductors, and it will be convenient
to follow the sequence in the description of the various forms of paralysis
of the recurrent nerve fibres.

Abductor or Posticus Paralysis. — Unilateral Posticus Paralysis. —
The vocal cords are abducted by the crico-arytenoideus posticus muscle on
either side, conveniently spoken of as the posticus muscle, paralysis of which
results in the vocal cord being maintained in the median line owing to the
normal tonus of the adductor muscle not being counterbalanced, so
that even on deep inspiration the affected muscle persistently remains in
the middle line, i.e. the phonatory position. As speech is not interfered

LAEYNX, NEUROSES OF 397

with, and the normal abduction of the unaffected cord leaves sufficient
space for quiet respiration, there are no symptoms to direct attention to the
larynx, and therefore the condition is frequently overlooked.

The left cord is most frequently affected, and is generally the result of
pressure on the left recurrent nerve by an aneurysm of the aortic arch.
Foreign bodies in the oesophagus, cancer of the oesophagus, mediastinal
growths, goitre, and on the right side tubercular disease at the apex of the
lung, or aneurysm of the innominate artery, are all possible causes.

Bilateral Posticus Paralysis. — When both cords are affected they remain
in the median line, the glottic aperture being reduced to an extremely narrow
aperture. Eespiration, of course, is greatly embarrassed, and during attacks
of dyspnoea the vocal cords are liable to be drawn together by the violent in-
spiratory efforts, so that very little air can enter the chest, and urgent or
fatal asphyxia may at any time arise. The voice is unaltered, and it may
be difficult for the patient to realise that he is the subject of a very
dangerous form of vocal cord paralysis. Fortunately it is rarely that both
cords are simultaneously affected with an extreme degree of posticus
paralysis, so that with few exceptions the posticus paralysis is incomplete,
or the implication of the recurrent nerve has gone beyond posticus paralysis,
and has resulted in total paralysis. The chief causes of bilateral paralysis
of the abductors are nuclear degeneration in the bulb due to syphilis,
diphtheria, or tabes dorsalis, or bilateral enlargement of the thyroid gland.
Occasionally aortic aneurysm involves both recurrent nerves.

Paralysis of the Internal Tensors of the Vocal Cords. — The action
of the thyro-arytenoideus internus muscle is to make tense and straight the
free margins of the cord during phonation, coughing, etc., paralysis of the
muscle, causing the edge of the cord to be slack and concave in outline, so
that the margins of the two cords are imperfectly approximated, and leave
an elliptical space during attempted phonation. The voice is consequently
weak, husky, or altogether lost, but respiration is not interfered with.

This is the commonest form of myopathic laryngeal paralysis, and
generally results from catarrhal laryngeal conditions, or from overstraining
of the voice — except when it is associated with abductor paralysis and is but
one of the series of laryngeal muscles involved in lesions which progress to
complete vocal cord paralysis.

Paralysis of the Adductors of the Vocal Cord. — The vocal cords
are adducted by the crico-arytenoidei laterales muscles which cause them to
meet in the median line, though for adduction of the cords to be complete
the arytenoid cartilages must be simultaneously approximated by the
arytenoideus and thyro-arytenoidei externi muscles.

Unilateral paralysis of the adductors alone is extremely rare. It would
resemble in appearance a complete paralysis of one vocal cord, but might be
distinguished by observing the larynx, not only during phonation and quiet
respiration, but also during deep inspiration, when, if the adductor was-
paretic only, further abduction would take place. In complete adductor
paralysis the vocal cord would be completely abducted, and show a concave
margin.

Bilateral Adductor Paralysis. — This form of paralysis is hardly ever
complete. The paretic adductors during voluntary phonation are able to
approximate the vocal cords in some measure, but not sufficiently to make
them meet, consequently the patient is aphonic, though abduction, and,
therefore, respiration, is not interfered with.

The causes are nearly always cortical and functional, adductor paralysis
being due either to hysteria or to general weakness.

398 LAEYNX, NEUEOSES OF

Paralysis of the inter -arytenoideus muscle, at any rate when apparent, is
always bilateral. The action of arytenoideus is to approximate and to
rotate outwards the arytenoid cartilages during phonation. Paralysis of this
muscle results in a triangular chink being left between the vocal processes
during phonation ; the voice is therefore very weak or lost.

It is always due either to hysteria or to catarrhal laryngitis.

Total Eecurrent Laryngeal Nerve Paralysis results in complete
paralysis of the vocal cords, " laryngoplegia," or unilateral complete paralysis
(" laryngo-hemiplegia "). The vocal cord remains in the cadaveric position
during respiration, and, except when it is helplessly pushed aside by the
over-adduction of the healthy cord, in phonation also.

The normal abduction of the other vocal cord leaves sufficient space for
ordinary respiration, but, although the voice is sometimes lost, ordinary
quiet conversation is generally possible, and the voice is sometimes almost
normal from the over-adduction of the healthy cord causing it to pass across
the median line to meet its paralysed fellow.

The laryngoscopic appearance is characteristic, for during deep respira-
tion the paralysed cord remains immobile, while in phonation the healthy
cord is over-adducted and passes obliquely across the median line, appearing
also to lie on a slightly higher level than the paralysed cord.

Diagnosis of Laryngeal Paralysis. — Two questions arise in connec-
tion with the diagnosis of laryngeal palsy ; firstly, " What muscles are
paralysed ? " and, secondly, " What is the cause of the paralysis ? "

Bilateral adductor or internal tensor paralysis or paresis, or paralysis of
the arytenoideus muscle, is easily recognised by the larygnoscopic appear-
ance and failure of the vocal cords or arytenoid cartilages to come into
apposition in the median line during phonation ; while unilateral adductor
paralysis is never observed, or only so rarely as to constitute a clinical
curiosity.

Posticus or abductor paresis may be simulated in nervous patients by
partial adduction of the cords during inspiration under laryngoscopic
examination. The patient should be instructed to sound a sustained note
as long as he can during the laryngoscopic inspection, for when the breath
is exhausted an involuntary deep inspiration will be made, and the vocal
cords will then abduct to their fullest extent, and then any appreciable
diminution in the abduction of one or both cords will be obvious. Complete
unilateral or pronounced bilateral posticus paralysis is easily detected ; the
difficulties should only be possible in the earlier stages when the abduction
of the vocal cord is defective, not absent.

The greatest diagnostic difficulty is the differentiation between true
total paralysis of a vocal cord and anchylosis of the crico-arytenoid joint.

Anchylosis of the crico-arytenoid joint is nearly always the result of
inflammatory infiltration in the tissues in the neighbourhood of the capsule,
and the obvious swelling or deformity produced usually suffices to dis-
tinguish between a mechanical fixation of the cartilages and a true paralysis.
But in many cases the inflammatory exudation has subsided, leaving the
joint more or less fixed, yet without obvious deformity or swelling, while in
others the joint lesion has been of a more chronic character, the " adhesive "
form with inflammatory degeneration rather than exudation. I have often
been able to distinguish between such cases of anchylosis and a true
paralysis by the fact that in total unilateral paralysis the arytenoid carti-
lage itself is obviously pushed aside by the over-adduction of the healthy
cord during phonation, whereas when anchylosis has occurred the arytenoid
cartilage remains absolutely fixed under all circumstances. But in course

LARYNX, NEUROSES OF 399

of time a simply paralysed cord becomes more or less fixed from prolonged
inactivity.

As regards the pathological diagnosis the following table, taken from
Watson William's Diseases of the Upper Respiratory Tract, summarises
under these headings the various diseases which may cause laryngeal
paralysis : —

1. Cortical Lesions. — Hysteria.

(Very rarely indeed organic lesions involving the cortical centres on both
sides.)

2. Bulbar Lesions. — Nuclear degeneration due to syphilis, diphtheria, loco-

motor ataxia, general paralysis, disseminated sclerosis, amyotrophic

lateral sclerosis, labio-glosso-laryngeal paralysis.
Syringomyelia.
Haemorrhage and softening.
Tumours.

3. Peripheral Lesions. — Pachymeningitis.

Intracranial new growths.

New growths in the neck, involving the vagus at the base of the skull.

Goitre.

Pericarditis.

Aneurysm of the aorta, right innominate, or the subclavian or carotid

arteries.
Intrathoracic tumours.
Cancer of the oesophagus.

Pleural thickening at the apex of the right lung.
Enlarged bronchial glands to various tuberculous lesions.
Injury to the nerves.
Neuritis, either rheumatic, alcoholic, syphilitic, or due to typhoid fever,

lead, arsenic, phosphorus, or other toxic causes.

4. Inflammatory Lnflltration of the Muscles.

Further, paralysis of the larynx may be simulated by mechanical
fixation of the crico-arytenoid joint.

It will be observed that paralysis or paresis of the laryngeal muscle may
be due to lesions in any portion of the motor nerve tract from the cortex to
the termination of the nerve fibres in the muscles ; but "numerous as are the
possible causes, the particular variety of paralysis that must result in the
different pathological conditions may be often determined by simply bearing
in mind the facts to which attention has been drawn in the introductory
remarks on p. 390. It will be seen that —

(a) Lesions of the cerebral cortex or internal capsule producing paralysis
must involve the centres of both cerebral hemispheres, and are therefore
almost invariably functional diseases, such as hysteria, or weakness from
exhausting diseases, anaemia, etc.

But we have seen that the laryngeal function of respiration (abduction
of the vocal cords) is mainly represented in the bulb, whereas the phonatory
function is represented mainly in the cerebral cortex ; therefore cortical
lesions only result in adductor paralysis or paresis of the vocal cords during
phonation. Thus we find that hysterical or other functional paresis of the
vocal cords involves the adductors only. Moreover, as the bulbar centres
are still active, the purely reflex act of coughing is attended with normal
adduction of the cords. Thus the cough of a hysterical patient is a
phonetic cough.

(&) Lesions of the bulbar nuclei involve both the postici or the abductor
muscles (respiratory), and also, though later in all progressive lesions, the
adductors of the cords. The diseases which are liable to be attended with
nuclear degeneration in the bulb are tabes dorsalis, bulbar paralysis, general
paralysis, syringomyelia, syphilis, diphtheria, etc. In these progressive nuclear

400 LAEYNX, NEUBOSES OF

degenerations the muscles are involved in a definite sequence according to
Sernon's law, and therefore the laryngeal paralysis involves first the postici
(abductors), then the thyro-arytenoidei interni, and finally the adductors,
with consequent complete paralysis of one or both vocal cords. The bulbar
lesion, and therefore the vocal cord paralysis, may be unilateral or bilateral,
but it will be gradual in onset. But in bulbar lesions, once the adductors
are involved, the paralysis is complete on both sides, there is no phonetic
cough.

(c) Of peripheral nerve -trunk lesions a basal meningitis is likely to
involve both sides. Outside the skull a goitre or a malignant growth of the
oesophagus are the only lesions likely to involve ■ both motor nerves. The
most common cause of peripheral nerve paralysis of the larynx is aneurysm
of the aortic arch, which by gradual pressure on the left recurrent nerve
causes a progressive paralysis of the left vocal cord. Here again the vocal
cord muscles are involved in the sequence laid down by Sernon's law.

Peripheral neuritis involving one or both recurrent nerves may result
in enteric fever, pneumonia, diphtheria, rheumatism, alcoholism, etc.

(d) Paralysis due to direct involvement of the muscle fibres or of the
nerve -endings in the muscle, the so-called myopathic paralyses, are the
result of local inflammatory changes, and as any individual muscles may be
implicated according to the seat of inflammation there is no definite
sequence in the order of paralysis.

The most common form of myopathic paralysis is that due to laryngitis,
with paralysis or paresis of the internal tensors of the cords, or of the
arytenoideus ; or one or both adductors may be involved. Any local
inflammatory affection, such as tuberculosis, syphilis, perichondritis, may
implicate particular muscles.

Treatment. — Inasmuch as the great majority of cases of laryngeal
paralysis are the result of pathological conditions in other regions, the
treatment of the paralysis very often resolves itself into therapeutic
measures directed solely toward these outlying causes, and therefore out-
side the scope of this article.

But there are two groups of laryngeal palsies for which local treatment
is desirable, viz. functional palsy, and palsy due to local inflammatory infil-
tration or to peripheral neuritis.

Functional adductor paralysis in hysterical or ansemic patients is an
indication for general hygienic measures, and the administration of nervine
tonic, iron, etc. In most cases it is possible to obtain an immediate and last-
ing cure of the aphonia by intralaryngeal faradisation with a strong current.
For this purpose one pole of the battery is connected with the episternal
notch externally, and a special intralaryngeal electrode is passed into the
larynx under the guidance of the laryngoscopic mirror, and the circuit
completed. With a fairly strong current the resulting spasm of the larynx
and the pain produced cause the patient to utter an exclamation, and on
withdrawing the laryngeal electrode the voice is usually found to have been
restored. Sometimes the aphonia recurs at short intervals for a time, but
after the restoration of the voice by the intralaryngeal faradisation on two
or three occasions the cure is generally permanent.

In laryngeal palsy due to diphtheria or other forms of neuritis, or in the
more persistent forms of paralysis following catarrhal affections, the intra-
laryngeal faradic current is often of great service, but in these cases a single
application is rarely sufficient ; often enough it must be persisted in for a
considerable period. In neuritic palsies the submucous injection of strych-
nine into the affected muscles may be tried with advantage.

LAEYNX, NEUKOSES OF 401

In the more gross inflammatory lesions ice should be sucked, and counter-
irritation in the form of mustard leaves, or the application of cold wet
compresses, will be helpful.

In bilateral abductor paralysis fatal asphyxia may arise at any moment,
and therefore the patient should be either placed under such circumstances,
that tracheotomy can be performed whenever the necessity arises, or else
tracheotomy or intubation should be performed. Intubation is not desirable
except in those cases in which, owing to the nature of the lesion, recovery
from the paralysis is possible.

When laryngeal paralysis is produced by a section of the motor nerve,
either in attempted suicide or in the removal of growths in the neck, the
cut ends should be sutured, just as in similar lesions of other nerves.

Hypertrophy of the Lingual Tonsil1

The lingual tonsil resembles the faucial pharyngeal tonsils in its
development, anatomical structure and in the pathological conditions to
which it is subject. It is, however, developed later than these other
aggregations of lymphoid tissues, and in early childhood is often small and
ill-developed, and it is partly due to these facts, and partly to the special
factors which result in its hypertrophy, that pathological conditions of the
lingual tonsil are more prone to appear in adult life.

Chronic enlargement of this tonsil may be due to previous acute lacunar
or parenchymatous inflammatory attacks, but it may arise de novo as the
result of chronic pharyngitis, or of long persistence of any of the many
causes which commonly lead to chronic pharyngitis. Irregular rounded
masses of the hypertrophied lymphoid tissue may then be observed by
simply depressing the tongue, though better seen by the laryngoscopic mirror.
The hypertrophic tonsil may overlap or impinge against the upper surface
of the epiglottis, concealing more or less completely the glosso-epiglottic fossse.

In many individuals very considerable enlargement is unattended with
symptoms, and these are without any clinical importance. But various
symptoms are liable to arise — especially a constantly recurring troublesome
cough, a sense of persistent discomfort, or a dragging sensation in the
throat, or vocal impairment.

As in chronic pharyngitis, so in lingual tonsillar hypertrophy, long-
standing irritation is liable to result in some measure of congestion, and
the veins ordinarily seen at the dorsum of the tongue may become enlarged
and tortuous. It has been stated by some observers that this enlargement
of the veins, which has been dignified with the name of lingual varix, is
itself the cause of numerous local and reflex symptoms and of grave dis-
comfort ; but from personal examination of a very large number of patients
who complained of no throat symptoms whatever, I am able to assert that
pronounced enlargement of the dorsal lingual veins is so frequently present
in patients past middle life as to be practically a normal condition, and
without clinical importance.

A lingual accessory thyroid gland is occasionally developed, appearing
as a smooth, firm, round red swelling in the region of the foramen csecurn.
It consists of thyroid gland tissue, whereas simple hypertrophy of the
lingual tonsil is composed of lymphoid tissue. The symptoms are very
much the same in either form of enlargement, and the two conditions may
easily be mistaken from one another.

1 Although in no wise a neurosis of the larynx, it is convenient to describe this condition in
the present section (vide symptoms, supra).

VOL. VI 26

402 LAKYNX, AFFECTIONS OF THE CAETILAGES

Treatment. — Simple adenoid hypertrophy when productive of symptoms
should be removed, either by repeated applications of iodine in solution
when the hypertrophy is only of moderate dimensions, or by ablation with
a lingual tonsillotome when considerable in amount.

Galvano-cauterisation is followed by much pain, and in some cases it
has resulted in severe attacks of parotitis. For these reasons its employ-
ment for reducing the hypertrophy is generally undesirable.

An accessory thyroid gland may be removed either by galvano-caustic
snare or by enucleation. But it is necessary to ascertain whether the
normal thyroid gland is absent, in which case the lingual thyroid gland
tissue should not be extirpated for fear of causing myxcedema.

LITERATURE. — Burger. Die Laryngealen Storungen der Tabes Dorsalis. Leiden, 1891.
— Heymann, P. " Beitrag zur Lehre von den toxischen Lahrnungen der Kehlkoffmuskulatur,"
Arch. fur. Lar. etc. v. 256. — Semon, Felix. "Die Nerven Krankheiten in Larynx und
Trachea," Heymann's Handbuch der Krankheiten des Raiser %md der Nase. Berlin, 1897. —
Semost, Felix, and Horsley, Victor. "An Experimental Investigation of the Central
Motor Innervation of the Larynx," Phil. Trans, of the Ryl. Soc. vol. clxxxi. pp. 187-211. —
Watson Williams, P. Diseases of the Upper Respiratory Tract : the Nose, Pharynx, and
Larynx. Fourth edition. Bristol.

Affections of the Cartilages

Perichondritis —

2. Anchylosis of the Crico-

Etiology and Pathology

. 402

arytenoid Joint

405

Symptomatology

. 403

3. Stenosis op the Larynx .

405

Diagnosis .
Prognosis .

. 404
. 404

Treatment ....

405

1. Perichondritis

Etiology and Pathology. — Perichondritis of the larynx may be denned
as an inflammation of the perichondrium covering the laryngeal cartilages,
characterised in some cases by suppuration, with necrosis and exfoliation
of the cartilage in whole or in part, in other cases by a plastic inflammation,
with the formation of new fibrous connective tissue.

The cartilages of the larynx, the surfaces of which are covered with peri-
chondrium, are the cricoid, thyroid, two arytenoids, and the yellow fibro-cartilage
of the epiglottis. Their various surfaces lie in relation to the interior of the
larynx, the oesophagus, the pharynx, and the subcutaneous tissue of the neck. As
the inflammation very rarely attacks the whole larynx, and sometimes only part
of one cartilage, the symptoms and signs will vary according to the surface thus
affected. Perichondritis may spread from one aspect to the other, so that an
inflammation of the thyroid cartilage, which may in the first instance be entirely
extra-laryngeal, may later involve its deep surface. Further, the disease may
spread from one cartilage to another, and even to the upper rings of the trachea.
The arytenoid cartilages are most frequently affected, probably from the fact that
tubercular ulceration is most common in that region ; the cricoid cartilage
occupies the second position in order of frequency. It occurs more frequently in
males. The disease may be of primary origin, or secondary to a pre-existing
laryngeal lesion. A few cases of primary affection have been recorded to which
no definite cause could be assigned. It is probable that some of these cases at
any rate were of the nature of a local septic infection. Perichondritis is much
more frequently a secondary affection, and occurs in the course of tubercular,
syphilitic, and malignant disease of the larynx. It is also the common form of the
laryngeal complication which arises in typhoid fever, and it is met with also in
small-pox, scarlet fever, and diphtheria. Further, it may be secondary to deep-
seated suppuration in the neck, or originate as a metastatic abscess in acute
general septic conditions. Perichondritis may also be of traumatic origin, occurring
after cut throat or other wounds of the larynx, or as a sequel to scalds and the

LAEYNX, AFFECTIONS OF THE CAETILAGES 403

action of corrosive irritants. It may follow the lodgment of foreign bodies, or the
frequent introduction or retention of oesophageal tubes, while more than one
author considers that the pressure of the larynx against the bodies of the cervical
vertebrae in the prolonged dorsal decubitus of old people may set up an inflamma-
tion of this nature.

Inflammation of the perichondrium is characterised in its earlier stages by
small cell infiltration and thickening of the fibrous covering and by serous
exudation beneath it, while a considerable amount of oedema may permeate the
surrounding submucous tissue. Subsequently pus forms under the perichondrium,
and as the cartilage thus becomes deprived of its nourishment necrosis and
separation in whole or in part may result. When the abscess thus formed breaks
through the mucous membrane the pus is discharged into the larynx, pharynx, or
oesophagus, or even externally under the skin, according to the situation of the
perforation. In the latter event a fistula is formed, a condition which may be
still further complicated by the occurrence of subcutaneous emphysema. The
necrosed cartilage may be coughed up or discharged through the fistulous opening.
In milder forms of the inflammation no suppuration and destruction of cartilage
takes place, but the perichondrium becomes thickened in consequence of the
formation of new fibrous connective tissue. As a result of these inflammatory
changes considerable cicatrisation, permanent thickening, and deformity take
place with consequent stenosis of the larynx. Another important sequela of
perichondritis of the arytenoid or cricoid cartilages, and one of considerable
clinical importance, is anchylosis of the crico-arytenoid joint, with impaired
mobility or complete fixation of one or both vocal cords ; this subject will
presently be referred to in more detail.

Symptoms and Signs. — The local symptoms met with are hoarseness
and aphonia, cough, pain, difficulty in swallowing, and finally dyspnoea, all
of them symptoms which may occur in other conditions. They vary,
however, and are considerably modified according to the severity of the
attack and the site of the lesion. In the acute cases a considerable amount
of constitutional disturbance occurs. If the inflammation attacks the
laryngeal surface of the thyroid cartilage interference with the voice is an
early symptom, but if the arytenoids are affected, dysphagia in addition is
complained of. If the lesion is confined to the posterior surface of the
cricoid cartilage or the epiglottis, difficulty in swallowing may be the only
symptom. Dyspnoea usually occurs in the later stages of perichondritis,
when the swelling becomes marked, but it must be borne in mind that
sudden dyspnoea may supervene even in the early stages of thyroid and
cricoid perichondritis. The detection of fragments of cartilage in the
sputum renders the diagnosis certain. If the inflammation is confined to
the external surface of the thyroid and cricoid cartilages, as may be the
case in the early stages of certain cases, swelling in the neck and pain with
increased tenderness on palpation may be the only indication of the local
condition.

The laryngoscopic appearances also vary considerably. If the arytenoid
cartilage is affected there is considerable swelling in that region, which in
some cases closely resembles the pear-shaped mass seen in tubercle of the
larynx. If the posterior part of the cricoid is at the same time involved
thickening of the posterior laryngeal wall is especially noticeable. There
may be impaired movement or complete immobility of one or both vocal
cords. A small yellow spot upon the mucous surface is an indication that
the abscess is pointing. Should this already have burst the pus may be
visible. If a probe can be successfully introduced into the sinus the
denuded cartilage may be felt. Involvement of the cricoid cartilage, either
along with the arytenoid or alone, may be evidenced by swelling of the
posterior laryngeal wall, of the ary- epiglottic folds, or of that surface of the
larynx which is directed outwards to the pyriform sinus. One or both
vocal cords may be fixed, perhaps, in the middle line as the result of

404 LABYNX, AFFECTIONS OF THE CAETILAGES

destruction of one or both of the posterior crico-arytenoid muscles. In
some of the early cases swelling may be detected beneath the cords, the
movements of which are somewhat impaired. "When the inflammation
attacks the laryngeal surface of the thyroid cartilage swelling may be
observed either above or below the anterior commissure of the cords, and
tending to occlude the glottic chink. In the former case the true cords
may be more or less concealed from view. Should the external surface of
this cartilage be affected, and present those signs already indicated above,
examination with the mirror may assist the diagnosis by disclosing the fact
that the mucous membrane on the affected side is reddened, and the
mobility of the vocal cord impaired. Should the epiglottis be affected
its posterior surface may present considerable swelling, which is seen to
extend downwards on to the aryepiglottic folds and false cords simulating
the cedematous infiltration observed in tubercle. The abscess may point
and rupture near the free margin of the epiglottis, or it may burst at a
more dependent part, and the sinus thus be invisible by laryngoscopy.

Diagnosis. — From the foregoing description, it is evident that the
diagnosis of perichondritis of the larynx is sometimes beset with difficulties.
The clinical picture is not a distinctive one. Neither the symptoms nor
the local appearances can be described as characteristic of the condition.
In the majority of cases they are identical with those of the primary disease
of which the perichondritis is merely a secondary complication. The
ulceration and infiltration of tubercle, syphilis and malignant disease may
later be marked by the onset of this complication, while a considerable
amount of acute oedema may obscure not only the original disease but also
the perichondritis. If it can be ascertained from the history that laryngeal
symptoms have existed for a space of time, and if those symptoms have
become somewhat suddenly aggravated and possibly accompanied by
difficulty in respiration, the existence of this complication must be suspected.
If the mirror reveals at the same time considerable swelling and a yellow
area on the surface of the mucosa, signifying the existence of pus, or if
necrosed cartilage can be detected with the probe or discovered in the
sputum, the diagnosis can no longer be a matter of doubt. The diagnosis
between true paralysis of a vocal cord and the fixation following the more
chronic adhesive form of perichondritis, or an anchylosis of the crico-
arytenoid joint, is sometimes very difficult. In some cases, again, the
diagnosis may only be cleared up by observing the result of treatment,
while in others the exact condition is not ascertained until a post-mortem
examination has been made.

The prognosis as regards life must depend to a considerable extent
upon the nature of the primary affection. In tuberculosis and malignant
disease it is grave, while in syphilis or following traumatism it is more
favourable; Death, however, may occur suddenly from asphyxia quite
independently of any dyscrasia ; marked increase in the swelling, perhaps
the result of oedema, the rupture of an abscess, or the lodgment of a piece
of cartilage in the glottis, may cause sudden death. A fatal termination
from septic pneumonia may follow the introduction of pus into the bronchi.
In those cases in which the patient's life is not threatened, the prognosis as
regards the function of the larynx must be extremely guarded. In some
cases the resulting stenosis may be so marked that respiration through the
glottis is no longer possible, and the constant wearing of a tracheotomy
tube becomes necessary. In others, again, the voice remains affected, some
degree of hoarseness or aphonia bearing witness to the permanent deformity
which has resulted.

LARYNX, AFFECTIONS OF THE CARTILAGES 405

2. Anchylosis of the Crico-Arytenoid Joint

Impaired movement or complete fixation of this important joint may
occur from a variety of causes. The anchylosis may be true or false
according to the existence of changes within or external to the joint
capsule. Sometimes the fixation results from a luxation of the joint
surfaces. As we have already shown that anchylosis may follow peri-
chondritis of the arytenoid and cricoid cartilages, it follows that the various
conditions already enumerated as etiological factors of the former must also
be regarded as causes producing anchylosis. To the different affections
enumerated above we must add as further causes the changes met with
in and around the joint in gouty individuals, and the neuropathic
and myopathic paralyses which produce secondary joint changes resulting
from disuse.

As a result of the anchylosis the movements of one or both vocal cords,
as the case may be, are impaired or lost. A varying amount of infiltration
and swelling in and around the joint exists in most cases as a sequel of the
previously existing inflammatory process. The position of the cord varies
according to the position in which the joint has become fixed, and this will
vary from that of full adduction to that of complete abduction. Where the
anchylosis is produced by cicatricial contraction (false), these extreme
positions of the cords are more frequently found, while in true anchylosis
the cord more frequently is fixed in an intermediate position (cadaveric).

The symptoms of this affection must therefore vary considerably ; they
consist mainly in alterations in the voice and in some degree of dyspnoea,
both being determined by the position of the affected cord or cords. The
voice may be unaltered, it may be husky or completely lost. Dyspnoea,
which may be marked, results from the fixation of both vocal cords near to
each other.

The diagnosis is sometimes difficult, in other cases impossible, especially
when from the absence of any thickening about the arytenoid cartilage a
differentiation from true nerve paralysis is practically impossible. Semon
lays considerable stress upon the following diagnostic points : the presence
of tumefaction round an immobile arytenoid cartilage or an abnormal
position of the same, the presence of cicatrices or cicatricial distortion ; and,
lastly, fixation of the vocal cord in the abducted position.

3. Stenosis of the Larynx

After what has already been written upon perichondritis and anchylosis
of the crico-arytenoid joint in the two previous sections, little remains to be
added upon the subject of laryngeal stenosis. In addition to the many
laryngeal affections there enumerated, which may lead to some degree of
narrowing of the lumen of the larynx, we must mention a few in which no
antecedent perichondritis is found. To these must be added congenital
webs or adhesions between the vocal cords, the false membrane of diphtheria,
the acute oedema complicating septic inflammations, and the presence of
suspected foreign bodies, and lastly, bilateral abductor paralysis of the
vocal cords of neuropathic origin.

Treatment. — The treatment of perichondritis and its sequelae must be
considered under three heads : —

1. The treatment of the acute stage of the inflammation.

2. The relief of dyspnoea.

3. Treatment of the resulting deformity (stenosis).

406 LAEYNX, CONGENITAL LAEYNGEAL STEIDOE

1. During the stage of acute inflammation the patient must remain in
bed, and absolute rest of the voice must be insisted upon. Cold may be
applied to the larynx externally by means of a Leiter's coil or by an ice bag,
while further relief may be obtained by the sucking of ice. Some re-
commend the application of leeches over the larynx. If the pain is severe
opium is necessary ; the food should be soft, non-irritating, and cold. Some-
times all the nourishment must be given by means of enemata.

In the syphilitic cases potassium iodide should be administered in-
ternally in conjunction with mercurial inunction. If an abscess
bursts and continues to discharge, tonics and a nourishing diet become
necessary.

2. If dyspnoea threaten, scarification of the swelling may afford the
necessary relief, or in the event of the abscess pointing, incision should be
practised. Intubation may be possible, but if these methods fail to give
relief, or if the case has become an urgent one, tracheotomy must be
performed.

3. The treatment of the resulting stenosis, although a subject of great
importance, can only be briefly dealt with here. Dilatation with intubation
tubes or bougies, thyrotomy or the permanent use of a tracheotomy tube,
are the means at our disposal for such treatment. Gradual dilatation
by means of O'Dwyer's tubes has been successfully practised in those cases
of stenosis which have resulted from chronic cicatricial contraction of the
glottis, if the commencement of such treatment has not been too long
delayed. The size of the tube introduced is from time to time increased.
Similar results have been obtained by the temporary introduction of
Schroetter's tubes and specially devised cannulae. In a large number of
cases, however, dilatation does not prove satisfactory, and the patient is
subjected to considerable discomfort and annoyance without any advantage
accruing. Sometimes the thyroid cartilage is split (thyrotomy or laryngo-
fissure), the parts being thus thoroughly exposed, and the infiltrated tissue
dissected off with the object of enlarging the glottic aperture. In spite of
care taken in the after treatment to maintain the lumen of the larynx by
the passage of bougies, a relapse to the former condition follows in a number
of cases. The wearing of a tracheotomy tube permanently becomes in
many instances a necessity, which gives, however, to the patient the
greatest possible amount of comfort under the circumstances. Not only is
the risk of respiratory difficulty in this way overcome, but he is able, by
placing his finger upon the outer end of his tube to converse with those
about him often with considerable success.

Congenital Laryngeal Stridor

Synonyms : Infantile Laryngeal Spasm, Infantile Respiratory Spasm,
Respiratory Croaking, Congenital Laryngeal Obstruction.

Definition. — A condition of noisy breathing, due to interference with
the free entrance of air into the larynx, which begins at or soon after
birth, lasts more or less continuously for many months and disappears
spontaneously before the end of the second year.

Clinical Features. — In a typical and uncomplicated case of congenital
stridor, the infant who appears normal in other respects is noticed im-
mediately, or within a week or two after birth, to have noisy breathing.
The noise consists of a crowing sound accompanying inspiration which

LARYNX, CONGENITAL LARYNGEAL STRIDOR 407

rises to a high-pitched crow when a longer or more vigorous breath is
taken. Expiration is often accompanied by a short crow when the stridor
is loud, but at other times it is noiseless. Even in the most severe cases
there are occasional brief intervals during which there is no sound audible,
but with this exception the stridor goes on constantly when the child is
awake and sometimes even when he is asleep. Any emotional excitement
or any physical cause of deeper breathing, such as exposure to colder air or
exertion on sucking, is apt to intensify the sound. The child's power of
crying and coughing is quite unaffected. Although the breathing is noisy
it is not accompanied by the slightest distress, and there is no cyanosis.
There is, however, always marked inspiratory indrawing of the thoracic
abdominal walls, except in the very slightest cases.

The stridor increases in loudness during the first few months, and after
remaining about the same for a few more months gradually lessens and
disappears spontaneously in the course of the second year. Long after it
ceases to occur habitually, however, it is apt to be set up by emotional causes.

Etiology. — Great difference of opinion has been expressed as to the
causation of congenital stridor. A peculiarity of form of the upper
aperture of the larynx is present in most if not in all the cases. This
consists in an exaggeration of the normal peculiarities of the infantile
larynx. The epiglottis is more folded on itself, and the ary-epiglottic folds
consequently more closely approximated. They may even be found to be
almost touching in cases where the patient has died of respiratory disease
accompanied by dyspnoea. Some (Lees, Sutherland and Lack, Variot,
Refslund) have regarded this condition as a congenital malformation, and
thought it sufficient to cause all the symptoms. By others the symptoms
have been attributed to posticus paralysis (Robertson), or to adductor
spasm due to adenoids or some other source of irritation (Lori, E. Smith).
One writer has even blamed enlargement of the thymus (Avellis).

It is probable, however, that the essential elements of the causation of
the condition are two — (1) an arrest of development of the cortical structures
which control the co-ordination of the respiratory movements leading to a
choreiform respiratory spasm (not a spasm of the larynx only) ; (2) the
extremely soft collapsable character of the laryngeal structure naturally
present in the young infant. These act in the following way : l — The ill-
co-ordinated and spasmodic character of the breathing gives rise to a
constantly repeated sucking-in of the sides of the upper aperture of the soft
larynx, and leads very soon to its remaining indrawn and deformed, exactly
as the thorax assumes the form known as pigeon-breast when indrawing of
its lower segment is constantly repeated for a long period of time. The
stridor is probably produced partly at the abnormally approximated ary-
epiglottic folds and partly in the larynx proper.

Diagnosis. — The diagnosis is generally easy. The chief points to be
attended to are the time of onset of the symptoms, the evidence of
laryngeal obstruction (stridor and chest retraction) without any apparent
distress, and the presence of a loud, clear cry and cough.

In cases of compression of the trachea by caseous bronchial glands, the
stridor is mainly expiratory, the larynx does not move up and down as in
cases of intra-laryngeal obstruction, and there is much greater respiratory
distress.

Prognosis. — Uncomplicated cases tend to complete and spontaneous
recovery. The presence of respiratory spasm, however, constitutes a serious

1 For a fuller account, see a paper by John Thomson and Logan Turner, Brit. Med. Journ.
vol. ii. 1900.

408

LAEYNX, LAKYNGISMUS STRIDULUS

complication to inflammatory diseases of the respiratory organs, so that if
bronchitis or pneumonia occur the prognosis must be guarded.

Treatment. — ]STo form of treatment has usually any effect on the
continuation of the stridor, although cases have been recorded (E. Smith)
where removal of adenoids was followed by improvement. The child
should, of course, be carefully guarded against chills.

LITERATURE.— A vellis. Hunch, vied. Wochenschr. 1898, ISTos. 30 and 31.— Gee. S. St.
Bart. Hosp. Rep. vol. xx. p. 15. — Goodhart. Diseases of Children, 6th edit. 1899, p. 275. —
Lees, D. B. Trans. Path. Soc. Lond. vol. xxxiv. — Lori. Allgemeine Wiener med. Zeitung,
1890, No. 49. — Refslund, H. Munch, med. Wochenschr. 1896, No. 48. — Robertson. Journal
of Laryngology, Oct. 1891. — Smith, Eustace. Lancet, 25th May 1895, 8th June 1895, and
19th March 1898. — Sutherland and Lack. Lancet, 11th Sept. 1897. — Thomson, John.
Edin. Med. Journ. Sept. 1892. — Thomson, John, and Turner, Logan. Brit. Med. Joum.
1900, ii. — Variot, G. Journ. de clin. et de thirap. inf. 18th June 1896 and 9th June 1898.

Etiology .
Clinical Features

Laryngismus Stridulus

408
409

Diagnosis and Prognosis . 409
Treatment . . . .410

Synonyms : Child-crowing, Spasm of the Glottis.

Definition. — Laryngismus has been defined as "a sudden arrest of
respiration followed by a long-drawn crowing sound due to inspiration
through the narrowed glottis " (Barlow). While this is a good description
of the usual type of attack, the arrest of breathing may occur with the
thorax in the position of inspiration instead of in that of expiration, and
then there is no crowing heard. The most noticeable phenomenon in an
ordinary attack is a spasmodic closure of the glottis, but if the seizure is at
all severe the other muscles of respiration participate in the spasm to a
varying degree.

Etiology. — 1. Of the Tendency to Laryngismus.

Rickets. — In the great majority of cases laryngismus occurs in rickety
children, and it is certain that rickets is far the most important element in
its causation from a practical point of view. Whether it is as closely
connected with an active rickety process in the cranial bones, as Kassowitz
believes, is very doubtful; but its almost invariable association with
rickety phenomena, and its rapid recovery under treatment which cures
rickets, is beyond dispute.

Age, Sex, etc. — There are, however, several other most important
etiological factors. The disease generally sets in between the 6th and 24th
months of life, and it comparatively rarely begins before or after these
ages. It is commoner in boys than in girls. Several cases are apt to occur
in the same family.

Reflex Causes. — Such sources of reflex irritation as painful gums from
teething, and adenoid growths, are often thought to have something to do
with its causation. Enlargement of the thymus is no longer regarded as a
cause, but it is probable that enlargement of the bronchial glands may be,
and the presence of hydrocephalus certainly is so.

Time of Year. — As Gee and others have shown, the disease is much
more prevalent during the first half of the year than in the latter six
months. Thus in 100 consecutive cases seen by the writer, 81 occurred
between January and June inclusive, and only 19 between July and
December. This seasonal distribution has been attributed to the
children having been kept much in the house during the preceding months.

LAKYNX, LAKYNGISMUS STRIDULUS 409

It is also probable that the greater prevalence of cold winds (E. and N.)
during the spring months has something to do with it.
2. Of the Seizure.

Any shock to the nervous system, however slight, and any exertion on
the child's part, may bring on an attack in those who are predisposed.
Thus, the child very often has a paroxysm ou awaking from sleep, if
exposed to a draught of cold air, if frightened or annoyed in any way, and
during swallowing or straining.

Clinical Features. — Laryngismus does not often begin suddenly in a
severe form in children who are perfectly well. In most cases the patient
has been out of sorts for a week or two at least, and the attacks are at first
very slight, only becoming severe after the condition has lasted for some
time. The attacks themselves set in with great suddenness. The child,
who has been sleeping quietly or playing in a natural happy way, suddenly
stops breathing, looks scared, and throws his head back with the mouth
open. The chest is fixed and the body and limbs become stiff; the hands
are clenched and the feet rigid ; the face turns at first cyanotic and after-
wards ashy pale. There may be apparently a short loss of consciousness,
although this is not common, and a general convulsion may often come on.
After a few seconds of arrested breathing, the glottic spasm relaxes and
there is a long inspiration, accompanied by a loud crow which is inter-
mediate in character between the whoop of whooping-cough and the
stridor of croup. This is what happens in a severe seizure. There are,
however, great differences in the severity of the attacks as well as in their
duration and in the frequency of their occurrence. In very many cases a
few laboured inspirations accompanied by crowing are all that is to be
observed ; while on the other hand the spasm is occasionally so severe and
continued that the child dies in it. In some cases there are only a few
seizures in the course of the day ; in others there may be twenty, thirty, or
more. They are generally more frequent during the night.

As has been already mentioned, rickets is present in practically all the
cases. We very rarely find laryngismus in advanced rickets with great
deformity, but it is common in the comparatively well-nourished fat and
often rosy-cheeked children in whom the disease, although not far advanced,
is actively progressing. The children are very frequently also subject to
other nervous manifestations, especially to facial irritability (Chvostek's
symptom), tetany, and general convulsions. Thus, in 100 consecutive cases,
69 showed facial irritability, 12 had symptoms of tetany, and no less than
60 were said to have had general convulsions. Convulsions were much
more commonly observed in boys than in girls. In many cases in which
there is no regular tetany, Trousseau's symptom can be elicited (see
" Tetany ").

Diagnosis. — The disease with which laryngismus is most commonly
confounded is false croup or laryngitis stridula. From this it may be
distinguished by the absence of a croupy cough and other signs of laryngeal
catarrh, and of any fever. Also by the age of the patient, false croup being
comparatively rare in children under two years. The history of recent
convulsions and the presence of facial irritability, or tetany, are strongly in
favour of the condition being laryngismus.

The glottic spasm which is set up by a foreign body in the larynx
resembles closely in character that of laryngismus ; but the history of the
case will usually render the diagnosis easy.

Prognosis. — The prognosis is generally very good in uncomplicated
cases, as the great majority rapidly and completely recover under treat-

410 LATAH

ment. It must, however, always be guarded because so long as the child is
subject to even a mild form of the disease, a fatal seizure may possibly
occur at any moment. Should the child acquire any inflammatory disorder
of the respiratory organs, the presence of laryngismus constitutes a
dangerous complication.

Treatment. — As rickets is such an important cause of laryngismus, its
treatment naturally forms an essential part of the management of the case.
The diet is to be revised and the proteids and hydrocarbons in the food
increased if they are deficient. Cod liver oil is generally indicated, and
phosphorus (gr. 2^5- thrice daily) is also useful. The child must be taken
into the open air as much as possible. Eapid and striking improvement
almost always follows the regular use of the cold douche, and often this
acts like a charm. The douche may be given in the following way : — The
child is made to sit in a bath containing a small quantity of hot water
and, immediately, a jug of cold water (60° F.) is emptied over his back and
shoulders. He is then taken out and thoroughly dried before the fire and
rubbed till he is warm. This may be done once, twice, or even oftener
in the day, and is very beneficial even in cases where the child is
frightened by it. Sedatives, of which antipyrin and phenacetin are the
most useful, may also be given. Should there be constipation or an
unhealthy character of the motions, it is well to begin the treatment with
a dose of calomel. The inhalation of smelling salts' sometimes cuts short a
paroxysm.

LITERATURE. — Barlow, Thos. Keating's Cyclopaedia of the Diseases of Children, vol.
ii. p. 231.— Gay, Wm. Brain, vol. xii. Jan. 1890, p. 482. — Gee, S. St. Bart. Hosp. Rep.
vol. xi. 1875, p. 47. — Goodhart. Diseases of Children, 6th ed. 1899, p. 271. — Kassowitz.
Beitrage zur Kinderheilkunde, N.F. iv. 1893, S. 43. — Smith, Eustace. Disease in Children,
4th ed. — "West, Charles. Diseases of Infancy and Childhood, 7th ed. 1884, p. 193.

Latah . — A curious mental affection met with in the Malay Peninsula,
Java, and in certain parts of Russia, characterised by symptoms which
depend on an increased susceptibility to the influence of suggestion. It is
a peculiar emotional disease closely allied to those known as dancing mania
and the various religious psychopathies. " Under ordinary circumstances
the subjects of latah appear in no way different from their neighbours.
But on the occurrence of some sudden and startling impression, such as a
loud sound or anything calculated to produce a vivid impression, or on
witnessing particular movements, or on hearing peculiar sounds, or in
response to some overt suggestion by word, movement, or facial expression
on the part of an experimenter, they pass into a peculiar mental state in
which they involuntarily utter certain sounds or words or execute certain
movements. In other instances they will imitate words and movements,
or yield themselves to suggestions coming from others, or even from the
phenomena of external nature. During their hypnotic-like state, which in
some may last for a few moments, in others for an indefinite time, or
until removed by a contrary suggestion, although consciousness and intellect
are clear, and although strenuous efforts may be made to resist suggestion,
the victim is at the mercy of his prompter, and will inevitably follow any
lead indicated, no matter the consequences." (Manson.) This extract
briefly indicates the leading features of the disease. For further information
regarding this the reader is referred to the literature.

LITERATURE. — Clifford Allbutt. System of Medicine, vol. viii. with bibliography.

Lateral Curvature. See Spine.

LENS (CKYSTALLINE) 411

Lathy riasis. See Toxicology.

Lead Poisoning". See Tkades (Dangerous).

Lens (Crystalline).

. 413
. 413

Anatomy and Physiology

. 411

Microphalcia

Displacements

. 412

Coloboma

Lenticonus ....

. 412

See also Blood.

The term is applied to an increase above the normal of the leucocytes
per c.mm. in the circulating blood ; but it does not embrace the increase of
leucocytes met with in leucocythsemia. In conditions of health the average
number of leucocytes varies considerably in different individuals, but may
be said to be as a rule between 6000 and 10,000 per c.mm. It is impossible
to state exactly at what point the variation of the leucocyte number becomes
abnormal, but it may be stated that it is rare for the number to rise above
12,000 or to fall below 5000 without some abnormal condition being present.
The average normal number may be increased under certain physiological
conditions, and such a change is accordingly spoken of as physiological
leucocytosis. It occurs to a slight extent after a meal, — digestive leucocytosis,
— being usually most marked three or four hours afterwards. The increase
is said to be more pronounced after a diet rich in proteids, but in any case
it rarely exceeds 20 per cent of the normal number. The number of leuco-
cytes may also be increased during the later months of pregnancy, and to a
rather more marked degree after parturition. It is important that these
variations should be known and borne in mind, otherwise slight rises in the
leucocyte number may sometimes be misinterpreted. In infancy also,
especially in the few weeks following birth, the leucocyte number is
increased, and at this period the proportion of lymphocytes is unusually high,
being often about 50 per cent (see article on " Blood "). In these various
conditions of physiological leucocytosis, with the exception of the increase
in infancy, it has usually been found that the various forms of leucocytes
are uniformly increased ; but fuller details on this point are still desirable.
It is, however, with the leucocytosis occurring in disease that we have

LEUCOCYTOSIS 439

to do in this article, and we shall also treat here of the converse condition,
namely, a fall in the leucocytes — leucopenia. In the great majority of
cases of pathological leucocytosis, the increase in the number is due mainly,
and often exclusively, to an increase of the finely granular (neutrophile)
polymorpho - nuclear leucocytes. This is a well - established fact, and
accordingly the term " ordinary leucocytosis " is frequently used with the
significance that the increase is on the part of these cells. The term
lymphocytosis strictly means an increase of the lymphocytes per c.mm., but
is often used as indicating a percentage increase in the number of these
cells. The latter use of the term is somewhat unfortunate for scientific
purposes, as in many cases where the leucocyte number is diminished, the
relative proportion of lymphocytes is increased, whilst their total number is
not so. It is therefore advisable that the term should be only employed to
signify an actual increase of the lymphocytes. It may be stated here that
such actual increase is comparatively rare, if we except the lymphatic form of
leucocytheemia, and in some cases of tumours of the lymphatic glands. The
term eosinophile leucocytosis or cosinophilia is used to signify an increase in
the percentage number of the eosinophyle leucocytes. In this case the
percentage increase practically always indicates an actual increase. We
shall now consider more in detail these variations in the leucocytes as they
are met with clinically.

1. Ordinary (finely granular) Leucocytosis. — The ordinary leuco-
cytosis, due to an increase of the polymorpho-nuclear neutrophile leucocytosis,
occurs in a great many different conditions. Such conditions, which have
been variously classified, may be placed for convenience in the following
groups, but we shall have to consider afterwards whether in the different
groups the leucocytosis is not in nature essentially the same : — (a) Leuco-
cytosis in inflammatory and infective conditions; (b) Toxic leucocytosis;
(c) Post - hsemorrhagic leucocytosis ; (d) Cachectic leucocytosis, especially
associated with malignant diseases.

(a) The first group embraces a great many diseases, many of which have
now been proved to be due to special micro-organisms, whilst in others the
nature of the causal agent is still unknown. A well-marked leucocytosis is
common in pneumonia, erysipelas, diphtheria, scarlet fever, plague, small-pox
(in the suppurative stage), etc. ; in acute inflammatory processes, especially
when they are attended by suppuration, e.g. in peritonitis, arthritis, appendi-
citis, abscesses in internal organs, in most gangrenous inflammations, in
pyeemia, and in most cases of septicaemia. It will be noted that in the
majority of such conditions there is present a local lesion with emigration in
large numbers of the finely granular leucocytes into the tissues, and it may
be stated as a general rule that up to a certain point the leucocytosis is pro-
portional to the severity of the affection or the extent of the local lesion.
This rule, however, must be taken in a very general sense, as several factors
are involved. An empyema will be attended by a greater leucocytosis than
a small local abscess, but the degree of leucocytosis in pneumonia does not
vary strictly with the amount of lung tissue affected, just as the severity of
the disease does not depend on this alone. Further, there are variations
depending upon individual peculiarities, and when the affection becomes very
severe and marked toxasmia is present, the leucocytosis may diminish, and the
leucocyte number may even fall below the normal. The actual number of
leucocytes in such conditions as those mentioned, of course, varies greatly,
but 15,000 to 30,000 may be said to be the common upper limit. Leuco-
cytosis in which the number rises above 40,000 must be considered extreme.
Of the diseases mentioned, pneumonia is that in which the condition of

440 LEUCOCYTOSIS

leucocytes has been most fully worked out, and we may state the chief facts
by way of illustration. The number of leucocytes rises within an hour or
two after the rigor ; in fact, in some cases has been found to be raised even
at the time of rigor. The number rises with comparative rapidity, and
during the period of fever remains high, showing variations of irregular
type. It usually commences to fall a short time before the crisis, and falls
rather more gradually than the temperature does, hence on the day after
the crisis the number may still be a little above normal. During the
leucocytosis period the increase, as we have said, is on the part of the finely
granular neutrophile leucocytes. In delayed resolution the leucocytosis
persists, though usually diminished in degree, their proportion often rising to
90 per cent or even more. The lymphocytes may show a slight actual
decrease, and one striking and well-authenticated fact is that the eosino-
philes may practically disappear from the peripheral circulation, at least it
may be impossible to find a single example on examining a number of films.
At or shortly after the crisis the hyaline leucocytes may show a slight
relative increase, whilst the eosinophiles reappear in the blood, and a day or
two afterwards may show a percentage above the normal. A fall in the
temperature without amelioration in the condition, a "pseudo- crisis," is
usually unattended by diminution in the leucocytosis. Furthermore, in
very grave cases leucocytosis may be absent and leucopenia may be present
throughout the case, or a leucocytosis, present at first, may gradually dis-
appear and give place to leucopenia, even although the temperature remains
high ; sometimes also a few myelocytes may appear in the blood. These
conditions are always to be regarded as of grave significance. The blood
examination in pneumonia is undoubtedly of considerable value ; it may aid
the diagnosis in cases of deep-seated pneumonia ; it enables one to judge of
the significance of variations of the temperature ; and from what has just
been stated, it will be seen that it affords valuable assistance in the matter of
prognosis.

In the other diseases mentioned above the leucocytes show somewhat
analogous changes to those in pneumonia, though they may not be so
pronounced. The increase of the finely granular leucocytes is again the
prominent feature, whilst the eosinophiles are in most cases diminished and
not infrequently absent. The fall of the temperature by crisis is attended
by a disappearance of the leucocytosis, and a rise in the number of the
hyaline cells, and it may be of the lymphocytes, is not uncommon. Also it
may be stated as a general rule that the disappearance or absence of the
leucocytosis occurring in a disease (where leucocytosis is the rule) associated
with severe symptoms, is to be regarded as a graver sign than when leuco-
cytosis is well marked. The infective diseases in which a normal or sub-
normal leucocyte number is the rule are mentioned below.

(h) Toxic Leucocytosis. — The term is applied in a somewhat loose way to
conditions in which there is manifestly some toxic agent in the blood, but
in which there is no distinct evidence of infection. We shall afterwards
have to discuss whether the leucocytosis described under heading 1 is not
really of the same nature as toxic leucocytosis. Here we may mention as
examples, gout, some cases of malignant jaundice, acute yellow atrophy of
the liver, some cases of lead poisoning, chronic Bright's disease, etc. Leuco-
cytosis may be also produced by the administration of various drugs, e.g.
especially volatile oils, pilocarpine, etc., and has also been produced experi-
mentally by the injection of a great many different substances, as will be
described below. In such conditions the leucocytosis presents the same
characters as in the first group, but is on the whole less in degree.

LEUCOCYTOSIS 441

(c) Post-haemorrhagic Leucocytosis. — When a large haemorrhage occurs
leucocytosis appears usually within two or three hours, continues for a day
or two, and if there be no renewal of the haemorrhage, gradually disappears.
If, however, there are repeated haemorrhages and a condition of marked
anaemia results, the leucocytosis is found along with the anaemic conditions.
Though the increase is usually quite distinct the number does not often rise
above 15,000. Here the course is manifestly different from that in the two
previous groups. Its exact mode of operation is not quite clear, but it is
undoubtedly connected in some way with the process of dilution which the
blood undergoes after haemorrhage. It certainly is not due to retention of
the leucocytes in greater proportion than the red blood corpuscles, as it is
absent immediately after the haemorrhage, and takes some time to appear.

(d) The number of leucocytes in cases of malignant disease varies greatly,
but it may be said as a rule that where cachexia with considerable anaemia
is present, leucocytosis is the rule. This occurs both with cancer and with
sarcoma, but in some cases there is a considerable leucocytosis before the
cachectic stage is established. In extreme anaemia the presence of leuco-
cytosis with increase in the blood-plates and diminution of the haemoglobin
per corpuscle indicates a cachectic (secondary) anaemia.

Absence of Leucocytosis, Leucopenia. — The most important infective con-
ditions in which leucocytosis is absent are typhoid fever, malarial fever,
tuberculosis uncomplicated by suppuration or cavity formation, measles, and
most cases of influenza. In all these conditions the number tends rather to
be below than above the normal, and this is especially the case in typhoid
fever, notably in the later period of the disease. The diminution is chiefly
on the part of the finely granular cells, though the others may be slightly
affected. A leucocyte count of 3000 or 4000 in the third week of the disease
is not uncommon. This fact was, of course, of greater practical importance
before the introduction of the serum method, but even yet there occur cases
in which it is of value. In acute miliary tuberculosis the leucocytes are
usually about the normal condition, but in phthisis with cavity formation a
more or less marked leucocytosis is present. In connection with these facts
it must, of course, be kept in view that in the diseases where leucocytosis
usually occurs, it may be absent, or even a converse condition may be present,
as explained above.

It follows from what we have stated that the condition of the leucocytes
alone must not be accepted in any hard and fast sense in relation to diagnosis,
but from the same fact it is evident that when the diagnosis is otherwise
established, a variation from the condition usually present may be of great
importance. Thus, for example, the fall in the leucocyte number, without
corresponding fall in the temperature, is of grave significance, and in
typhoid fever the appearance of leucocytosis may suggest the presence of
some secondary inflammatory or suppurative complication.

Pneumonia has been specially mentioned as an example in which the
disappearance or absence of leucocytosis is of grave omen, but a similar
change may occur in other diseases. Thus it has been observed in some
forms of very grave septicaemia and in some cases of diphtheria. In fact, it
may be interpreted as evidence of a very high degree of general poisoning.
It must be clearly understood, however, that in many conditions a well-
marked leucocytosis may be present up to the time of death.

In addition to these more acute infective conditions, in which leucopenia
may occur, the number of leucocytes is diminished as a rule in various
chronic diseases. Among such may be mentioned pernicious anaemia,
chlorosis, some forms of severe anaemia attended with purpura, haemophilia,

442 LEUCOCYTOSIS

some cases of goitre, and certain cases with enlargement of spleen and
anaemia, to which the term " splenic anaemia " is given. Frequently in
such conditions the leucocyte number is about 3000 per c.mm. ; but in some
examples of severe pernicious anaemia the number may be uniformly about
1000 per c.mm. On the other hand, in some cases of pernicious anaemia the
number is little diminished below normal. We do not yet know the signifi-
cance, from a prognostic point of view, of these variations in different cases.
Here again the diminution is chiefly on the part of the finely granular
leucocytes, and therefore, according to the above definition, lymphocytosis is
present. In some cases of pernicious anaemia, for example, the lymphocytes
may number 80 per cent of the total number of leucocytes, but there is,
nevertheless, usually no actual increase in the number of lymphocytes. In
fact their number is more often below the normal than above it.

The Presence of Myelocytes. — These are large cells, often measuring 14 or
16 m. in diameter, with a rounded oval or slightly indented nucleus, poor in
chromatin, and with finely granular protoplasm. Their presence in large
numbers is an outstanding feature of the spleno-medullary leucocythaemia
or myelocythaeinia, and it was for some time believed that they occurred in
no other condition. More extended observations, however, have shown that
they appear in the blood, though in very small numbers, in a variety of
conditions. They are not infrequently met with, for example, in pneumonia,
and other conditions, especially when the conditions are of grave nature, and
the leucocyte number is low or falling. Even in cases running a favourable
course, with a well-marked leucocytosis, one or two myelocytes may be
present, and also, what is of some importance, a few cells intermediate in
character between them and the ordinary polymorpho-nucleated leucocytes.
In cases of grave anaemia, also, a few myelocytes may appear in the blood,
and in some cases of marked cachexia due to malignant disease a consider-
able proportion has been observed. It must be clearly understood that the
cells to which the term myelocyte is applied are those containing fine
neutrophile granules. This fact has not been sufficiently attended to, and
accordingly the larger hyaline leucocytes of the blood have been mistaken
for myelocytes, and error has accordingly resulted in the record of cases.
There can be practically no doubt that these cells are normally present in
the marrow only ; according to our opinion they are the progenitors of the
finely granular leucocytes of the blood. It is somewhat difficult to state
exactly ; the conditions on which their entrance into the blood - stream
depends, but it is of considerable significance that a few nucleated red blood
corpuscles are in a very large proportion of cases present in the blood along
with the myelocytes. This is not only the case in severe anaemia, but also
in severe infective conditions. We can only state that their appearance is
due to some disturbance of the cellular arrangement in the bone-marrow —
an arrangement by which both they and the nucleated red blood corpuscles
are prevented from entering the circulation in the normal state. Such a
disturbance may occur in the case of great dilution of the blood (anaemia),
as a result of toxic agency, as in many infective conditions, and in some
cases the result of tumour growth in the bone-marrow.

2. Lymphocytosis. — A percentage increase of lymphocytes, of course,
occurs where there is leucopenia with diminution in the finely granular leuco-
cytes (vide supra). An actual increase has been observed in malignant
disease affecting the lymphoid tissue, and also in some other conditions of en-
largement, e.g. tubercular, also in some cases of gastric and intestinal catarrh,
and in whooping-cough. The increase in these conditions appears to occur
more readily and to be more marked in children than in adults. According to

LEUCOCYTOSIS 443

Ehrlich's view, lymphocytosis occurs where a raised lymph circulation in a
more or less extensive area washes an increased number of lymphocytes out
of the lymphoid tissue, i.e. is the result of a mechanical process, as opposed
to chemiotaxis, which is the basis of ordinary and eosinophile leucocytosis.
Further investigation is, however, necessary before we can definitely exclude
chemiotaxis as a factor in the occurrence of lymphocytosis.

3. Eosinophile Leucocytosis. — Whatever may be the actual genetic
relationship between the finely granular and coarsely granular oxyphile
leucocytes of the blood, there is no doubt that in pathological conditions
they behave as two distinct classes, both as concerning their emigration to
the tissue and as regarding their variation in number in the blood. The
increase of eosinophiles has been specially studied within late years, and
now certain sets of conditions have been recognised in which it is the rule.
(1) In asthma there is often a most marked increase in the number of
eosinophiles, not infrequently up to 10 or 20 per cent ; the increase is most
marked during an attack of the disease. (2) In certain acute and chronic
diseases of the skin, pemphigus, urticaria, psoriasis, etc. Here again the
proportion of eosinophiles may be very markedly increased, though the total
number of leucocytes does not rise much above the normal. (3) In helmin-
thiasis eosinophilia appears to be the rule. In trichiniasis the increase is
very marked, and in one case, at least, the number observed was about 50 per
cent of the total number of leucocytes. In affections with other round-
worms, such as ankylostoma duodenale, and even ascarides and oxyurus ; in
fact this increase appears to be the rule. An increase in the eosinophiles
has also been observed in some cases of malignant disease, especially with
metastases in the bone -marrow; the post -febrile leucocytosis has been
referred to above.

With regard to diminution in the number of eosinophiles, the most
important condition is ordinary leucocytosis, especially those of rapid
occurrence, e.g. in acute pneumonia. As already mentioned, the leucocytes
may practically disappear from the blood, and in other conditions their
number may be at least very much diminished.

It is important to note that the eosinophiles are very numerous in the
bronchial secretion in asthma and in the affected tissues in those skin
diseases attended with eosinophilia. One other interesting point with
regard to such skin affections is that when an acute inflammatory or sup-
purative condition is added, the leucocytes which emigrate from the blood-
vessels are of the finely granular neutrophile variety. This would go to
show that in the particular affection there is present some substance which
acts chemiotactically upon or attracts the eosinophiles, but that agents
that produce through suppurative processes attract the neutrophiles. In
short, all the evidence goes to show that the two classes of cells are attracted
by different substances, but that their emigration into the tissue, and in-
crease in number in the blood, are brought about by similar mechanisms.

Nature of Leucocytosis. — We have so far considered the chief variations
in the different forms of leucocytes met with under clinical conditions, but
it is important that the vital processes underlying these variations should
be understood. The relations of the different forms of leucocyte are still
subject of controversy, and we shall only make general statements which
seem to us of importance, as well as justified by fact. If we look at the
question from the experimental side, we find that leucocytosis may be pro-
duced by a great variety of methods, the chief of which are the inoculation
with certain organisms and the injection of certain chemical substances.
Of the latter we may mention three chief groups as examples, viz. (a)

444 LEUCOCYTOSIS

Certain bacterial products or substances separated from bacteria; (b) Extracts
made from various tissues, especially those rich in cells, such as spleen,
lymphatic glands, etc. ; (c) Certain definite chemical substances, e.g. peptone,
curare, nucleic acid, etc. By the injection of these substances the number
of leucocytes may be doubled in the course of an hour or two, and in such
cases also the increase is on the part of the finely granular cells. What,
then, is the source of these cells added to the blood ? Ehrlich holds, and
our own observations completely confirm his contention, that the chief, if
not the exclusive, source of these cells is the bone-marrow, where they are
formed from the finely granular myelocytes. Further, in the normal con-
dition a considerable number of these polymorpho-nuclear leucocytes are
present in the marrow in close relation to the blood-stream, forming a
reserve store as it were. Thus a means is afforded for a rapid addition of
these leucocytes to the blood. There is, we believe, practically no doubt
that, just as in inflammation the emigration of leucocytes is guided in by
chemiotaxis, so also their passage from the bone-marrow into the blood is
brought about by a similar agency. We have also been able to show that
in long-standing suppuration, where there is a great drain on the finely
granular leucocytes, there also occurs a great increase of the finely granular
myelocytes, and evidence of increased multiplication amongst these cells —
a change which we consider can only be interpreted as a provision for the
increased demand. (To a marrow thus changed we have applied the desig-
nation " leucoblastic" as contrasted with the hcematoblastic type which
occurs after hsemorrhage.1) We may add that the arrangements in the
marrow are such as to bring the leucocytes in it directly under the influ-
ence of any substance circulating in the blood, and at the same time are
such as to admit their ready passage from the marrow into the blood. To
put the matter shortly, then, local suppuration is due to agencies exerting
positive chemiotaxis on the finely granular leucocytes. When these sub-
stances are absorbed in such cpuantities as to influence the cells in the
marrow, then a blood leucocytosis occurs. As we have already stated,
the mechanism of the eosinophile leucocytosis is in all probability of the
same nature, the eosinophile leucocytes being derived from the eosinophile
myelocytes.

We can therefore understand that in the various diseases the factor
determining the leucocytosis is not the high temperature, nor even the
extent of inflammatory change per se, but the presence in the blood of sub-
stances which exert positive chemiotaxis on the finely granular leucocytes.
According to this view, also, it is at once clear how that in practically every
case where there is an extensive inflammation, or, more accurately, an
extensive emigration of these cells, a leucocytosis is present, and it is also
equally intelligible how in various toxic diseases a similar leucocytosis
occurs without any local inflammatory change. In diseases such as typhoid,
malaria, etc., where there is no increase of the finely granular cells, there
is, in all probability, an absence of substances which exert positive chemio-
taxis. There are, therefore, two chief changes brought into play, viz. : (1)
the emigration from the bone-marrow ; and (2) increased formation in the
bone-marrow. With regard to the conditions in which the number of
finely granular leucocytes is below the normal, our information is of a less
definite character ; but the possible factors may, however, be said to be the
following: — (1) There may be structural change in the bone-marrow lead-
ing to diminished formation of these cells. This is possibly the condition
in some varieties of ansemia. (2) In certain diseases, e.g. in typhoid, the

1 For a further statement of these views see Brit. Med. Jo-urn. 1898, ii. p. 604.

LICHEN 445

fall in the number of leucocytes may be due to an increased breaking-down
of the leucocytes without a compensatory addition of leucocytes to the
blood, which, as we have stated, is brought about by chemiotaxis. (3) In
conditions attended usually by leucocytosis, e.g. pneumonia, septicaemia,
etc., the occurrence of a leucopenia may depend upon various circumstances.
Excessive emigration into the tissue, an extensive breaking-down of leuco-
cytes in the blood and spleen, a failure of the bone-marrow to keep up the
supply, and possibly an accumulation of leucocytes in the various organs in
coagula in the heart, etc., may be involved, but it is to be noted that all
these factors indicate a condition of gravity. Thus it is intelligible how
the replacement of leucocytosis by leucopenia without improvement in the
symptoms constitutes a grave omen. It is not, however, the diminution in
the number of leucocytes in itself, but the condition bringing it about, which
is the important element. On the other hand, the presence and continuance
of leucocytosis in the various diseases indicate at least that there is no
interference with the natural response to the demand for increased leucocyte
supply.

It will be apparent from what we have said that no simple rule of
universal application can be given as to the significance of leucocytosis.
One must know the conditions of the leucocytes usually found in each
disease running a natural course. Such information is of importance in
diagnosis, provided there be no complications. When, however, the diagnosis
is established, deviations in the condition of the leucocytes from that usually
present may be of aid in prognosis, and of these deviations the most im-
portant is the disappearance of the leucocytosis, or the appearance of leuco-
penia, without general improvement. We repeat again that mistakes are
liable to arise if an application of various hard and fast rules is attempted.
It is only by an intelligent consideration of the conditions present, in view
of the facts established with regard to the various diseases, that the condi-
tion of the leucocytes aids the diagnosis and prognosis. There is no doubt,
however, that, employed in this manner, examination into this condition is
an important addition to our methods of clinical observation.

LITERATURE.— Cabot. Clinical Examination of the Blood, 3rd ed. 1898.— Coles. The
Blood : How to Examine It, 1898. — Ehelich and Lazarus. Die Andmie, Abth. i., Wien, 1898.
Recently translated by Myers under the title Histology of the Blood, Cambridge, 1900. —
Geawitz. Klinische Pathologie des Blutes. Berlin, 1895. — v. Limbeck. Grundriss einer
klinische Pathologie des Blutes, 2nd ed. Jena, 1896. — Turk. Klinische Untersuchungen iiber
das Verhalten des Blutes bei acuten InfectionsJcrankheiten. Leipzig, 1898. These works give
full references to the separate papers on the subject.

Leucoderma. See Skin.

Leucorrhcea. See Vagina, Secretions from.

Leukoplakia. >&e Tongue.

Lichen.

Derivation and Definition of

THE TERM LlCHEN .

Varieties of

Lichen urticatus, strophulus,

tropicus, hcemorrhagicus,

lividus, pilaris, circum-

scriptus ....
Lichen scrofulosorum .
Lichen planus

Lichen verrucosus moniliformis

448

446

Lichen ruber acuminatus

448

446

Pityriasis rubra pilaris

448

Lichen ruber neuroticus

449

Parakeratosis variegata

449

Pathology ....

450

446

Etiology .....

451

447

Diagnosis .....

451

447

Treatment ....

451

446 LICHEN

The derivation of the term lichen is not clear. One can hardly believe that
it was selected as an appellation because one of the forms of lichen ruber
planus — the sole true lichen among many which have been rejected on various
grounds — somewhat resembles the botanical lichens which nourish on the
boles of old trees, for this variety in a pronounced guise is rare, and it is not
generally from rare varieties that generic designations become popularised.
But what is now meant by the name is obvious enough. It is applied
to diseases of the skin which are throughout papular, any change in feature
being due to alteration in arrangement, or to intensification of existing
characters, not to transformation into another type of lesion, or to the fact
that the lichenous is but a stage in the course of the ailment. The essential
truth of this definition may be averred, even though in very exceptional
instances some slight modification has been noted. These are mere chance
freaks.

The history of lichen proper does not actually date farther back than
the time of Hebra, and the conception he formed is adhered to now even
more closely than by its originator himself. But there are many cutaneous
complaints to which the prefix lichen was connected at no distant period,
now relegated to other categories, yet which require brief notice here in
order to clear the ground. Thus we have lichen urticatus, a form of
chronic urticaria seen particularly in young children, in which papules
evolve out of and succeed the wheals. Lichen strophulus, a punctiform
eruption of small, acuminate, red papules in infants, associated with profuse
sweating, favoured by or perhaps even due to unsuitable or to coarse
woollen underclothing. Lichen tropicus, also a sweat rash, seen chiefly in
warm climates, and there most frequently in new comers, and in one of its
types papular. It is caused by sudden blocking of the mouth of the
sudoriferous ducts, with cystic degeneration as a sequence. Pollitzer explains
its production as due to the soaking, by perspiration, of a skin insufficiently
supplied with fat. It may be that depriving the integument of its normal
unctuousness by too frequent baths with soap, predisposes, since it does not
appear to occur in the negro. Lichen hcemorrhagicus and lividus are mere
accidents in some papular efflorescences, when in consequence of intense
congestion blood is effused into the tissues, or owing to a scorbutic or pur-
puric element it oozes into the lesion. Lichen pilaris, though papular, dry
and permanent, is properly a keratosis of the upper half of the hair follicles.
It gives rise to the rough scaly points so frequently seen and felt on the
outer aspects of the upper arms and thighs. Or to the spiky prominences
— called also lichen spinulosus — inflammatory in nature, met with on the
neck, arms, and elsewhere, set with almost mathematical regularity, and
exhibiting, occasionally at least, contagious features, where the extruded
root-sheaths form short projections. Lichen circumscripta must now be
looked on as an extension of seborrhcea, and as constituting one of the
varieties of Unna's seborrhceic dermatitis. It occurs on the back between
the scapula?, or on the front of the chest, and is particularly prone to arise in
the case of those who habitually wear thick though possibly soft flannel
under-vests. Individually the elements are minute red or rose-red pinhead-
sized spots or elevations, which are follicular in situation. These have a
tendency while extending to arrange themselves as incomplete circles or
crescents, the included area being fawn-coloured, perhaps slightly scaly.
The periphery is a rose-red line, which in many instances can be resolved
into a chain of perifollicular papules. But occasionally the whole area is
rough, the projections being closely set over the entire field. Considerable,
even wide tracts may be involved, the skin in general is greasy, and there

LICHEN 447

is usually seborrhcea capitis, the starting-point, as it is the maintaining
source of the disease. The arrangement of the dorsal manifestation is
triangular with the apex downwards.

Lichen scrofulosorum occupies as yet an uncertain position. Though in
the large majority of instances it is encountered in children and young
adults who are evidently of the scrofulous type it has not yet been satis-
factorily proved to be tubercular by the unequivocal discovery of the
bacillus. It is an inflammatory process which has its seat in the immediate
neighbourhood of the pilo-sebaceous follicles. It runs a chronic course, and
its pinhead-sized papules are flattened and soft, of a pale red, brownish red,
or whitish tint. These are found in groups, or arranged in circular lines.
They bear a small scale on their summit, less often a tiny pustule. After a
rather prolonged duration they disappear. They are seen both on the front
and back of the trunk, but may be complicated by an impetiginous eczema
of the pubic regions and their neighbourhood, and give rise to a slight
sensation of itchiness.

The sole true lichen which remains is lichen planus. Its lesions occur
in two forms, as isolated papules, or when these become clustered into the
patch, in which circumstances they undergo some modifications. The
papules may be polygonal or round, pale, almost skin colour, or more
typically crimson or bluish red. Their surface is hard and smooth, so as to
impart a burnished appearance when viewed by oblique illumination. They
may remain discrete, dispose themselves in lines, or from progressive increase
in number may be so aggregated as to form patches. In both cases on
subsidence they leave behind a degree of brown pigmentation, sometimes an
atrophic depression, or the surface of the patch grows rugose and warty. A
peculiarity of lichen planus is polymorphism within certain limits, displayed
by the papules themselves and in their mode of coalescence. Thus the
colour varies from a pale to a crimson-red in the angular, in the round more
usually a bluish red, on the legs a dull purplish. The shape is determined
partly by the surface lines of the skin, partly also by the situation ; thus
they are flatter when they form round a sweat gland, more acuminate at a
hair follicle. At times the papule assumes an obtuse shape, having a con-
vex rather than a plane summit. On the lower limbs especially their
contour may be oval. Some exhibit a punctate depression in their centre,
more on stretching show fine whitish lines within their structure. Though
scaliness is not a feature of the isolated papule, it becomes pronounced on
the patch, and this hyperkeratosis takes on even extreme proportions on the
legs, where not infrequently a hard, gray, warty, veritably lichenous invest-
ment may be observed (lichen verrucosus). The patch, however, may on
the contrary be fairly smooth, indeed in some instances it much resembles a
dry erythematous blotch, only it does not wholly fade on pressure. At
other times it may show a species of cross-hatching, due to the approxima-
tion of angular papules. It is customary to find isolated papules in the
neighbourhood of a patch. Though the linear arrangement is the ordinary
a circular is not unknown. The elevation varies ; on the forearms it
is not great, is more evident on the back of the hand, and often con-
siderable on the lower extremities, particularly about the shins. The
pigmentation, too, differs. In some it is residual, not noticeable till
the papule has been absorbed, in others there is decided dark staining
round a patch, or even a papule, and this where no arsenic has been
administered.

The situations affected are to some extent characteristic. Thus the face
and scalp are avoided, while the wrists and flexor aspects of the arm, the

448 LICHEN

inner side of the thighs, and the front of the leg are favoured. It may be
limited to the scrotum, or to the penis, or its immediate vicinity. But
it occurs on any part of the trunk, pre-eminently where articles of dress press
on the skin, as at the waist or where garters are worn. On the palms
the papules are horny and may be smooth, but often by tearing through
the dense epidermis cause it to look ragged. Parts of the palm may
thus present a dry, cracked appearance. The nails seem never to be
involved.

On the tongue and buccal mucous membrane the tenderness of the
investing layer and the moisture alters the aspect. Hence in place of
definite papules there are milky white spots or patches. Occasionally un-
explained diarrhoea arises in course of lichen planus, and it has been surmised
that this may be due to the eruption of lesions in some part of the intestinal
tract. Nevertheless the general health seldom suffers.

So few cases of lichen moniliformis described by Kaposi and von During
have yet been encountered that its exact nature and its relationship to
ordinary lichen planus are undecided. Still, as papules such as those
described and pigmentary macules, the result of their involution, were also
perceptible, it would appear that this is but an extreme variant. The papules
are fused into lines or elevated ridges, longitudinal in direction, and found
chiefly on the throat or neck and flexor aspects of the limbs. The prominences
so produced resembled strings of coral beads or elongated nodosities of
keloid. The surface was glossy, brownish red in colour, and rather tender
to pressure.

Lichen planus may persist in a localised form, the chronic or commonest
type, or advance slowly and erratically, but in some cases it pursues an
acute course, invading the greater part of the covered portion of the body
in a short time, and appearing as a symmetrical eruption. The papules are
a more decided red, but are otherwise like those in the chronic variety.
Itchiness may precede the formation of the papules. Its degree varies ; it
may be trivial, or so intense as to preclude sleep. Both papules and patches
are numerous, diffused over a wide area, and there is more distinct scaling,
while pigmentation always supervenes. Though acute in its onset it may
only leisurely fade. Becurrences may occur more than once. Whether
treated or not the tendency is to disappear after a time, and this in the
chronic and acute variety alike. One may with truth say that recovery is
constant, but its date indefinite. The verrucous kind, whose seat -par
excellence is on the lower limbs, is peculiarly obstinate and offers marked
resistance to treatment.

While interspersed among the flat papules we may find some more or
less acuminate, yet the disease described by Hebra as lichen ruber acumin-
atum, in which all the papules were pointed and the termination mostly a
fatal one, unless arsenic were administered, has not so far been satisfactorily
identified. Two views are held with regard to this. One, that Hebra con-
fused with lichen planus a disease particularised by Devergie and known as
'pityriasis rubra pilaris. It is true that Hebra did not formulate an account
of this complaint in separate form, but it is probably an error to hold that
this ailment comprises all cases of Hebra's lichen ruber acuminatus. There
are many circumstances which render this idea unlikely. The name conveys
a good conception of the general features. Thus the fine, dry, white scales,
so abundant in some cases, make good the pityriasis; beneath these is
found a substratum of diffuse and unusual redness ; while pilaris indicates
that the hair system is chiefly implicated. It may commence by the forma-
tion of dry patches on the palms or soles, or with flaky seborrhoea of the

LICHEN 449

scalp or face. But in other examples the peculiar papules may appear
primarily on the trunk or limbs. These are conical, from a pin-head to a
hemp-seed in size, red, hard, and arid, showing a broken hair in the centre,
surrounded by a species of horny collar dipping down into the follicle.
They are, indeed, like lichen spinulosus, more widely distributed, but set
with great regularity at intervals very nearly exact. With an increase in
number they become crowded together so as to lose their obvious individuality.
The skin then feels thickened and immobile, looks reddish or yellowish, and
is covered with an investment of scales, either fine and branny, or massed
into the semblance of a coating of plaster or lime, but without trace of
moisture or oozing. As a rule isolated papules may be discovered at the
edges of the thickened areas, but the eruption may be so generalised that
the papular element is wholly or all but wholly concealed. Should the
epidermic accumulation be removed by oil-packing, then dull brownish red
papules, not altogether unlike those in lichen planus, are disclosed. A special
characteristic is the occurrence of papules corresponding to the hairs on the
dorsum of the first and second phalanges of the fingers. The nails are
usually attacked, are grayish and striated, while beneath them a soft concre-
tion forms like rush pith. The face is often covered with minute scales
and seborrhoeic accretions ; the integument is dry and stretched, giving rise
to ectropion. The course of the disease is subacute or chronic, with no
evident constitutional symptoms, the general health being well preserved
throughout. It may last for years, with temporary aggravations and
remissions.

But Unna and von During have met with cases, especially in an
epidemic which occurred in Hamburg, which they think approximate more
closely to Hebra's conception of lichen ruber. They state that it may
attack persons apparently in good health, more commonly it is ushered in
by feverishness, headache, and depression. Locally there is an erythroderma
at first limited and transitory, later spreading widely. Then small, red,
hard, conical, glancing papules, which are chiefly seated at hairs, but may
occur apart from these, develop. Many bear a scale. They may mass
themselves into patches, with infiltration of the skin and pigmentation.
The nails are seldom affected, but the hair falls off. The itching is intense,
there is sleeplessness, loss of appetite, emaciation, and weakness. The
disease is a severe one, and has ended fatally. Eeviewing the question,
Brooke thinks that there may be from time to time outbursts of this lichen
neuroticus, as Unna terms it, and that Hebra drew his picture either from
one of these, or he confused the three ailments together, working as he did
in the early days of dermatology.

There is still, however, another rare disease which has so far not been
exactly allocated. To it Unna has provisionally attached the name of
Parakeratosis variegata, and several instances have come under my notice.
The disease is an eminently chronic one, and may last very many years.
There are at first minute papules, very little elevated above the surface,
which arrange themselves in lines. In colour they are a dull crimson-red,
but have little if any of the burnish of those of lichen planus. Gradually
they arrange themselves so as to form a kind of meshwork, so that
the skin shows a mottled appearance, white spaces enclosed by crimson-
red boundaries. There may be slight desquamation. All the body, face
included, becomes affected, and the mottling gets less pronounced as the
white areas grow redder, till the surface is of a patchy plum colour. The
skin becomes thinned, and the hairs wax scantier and scantier everywhere.
Itchiness is present in some, not complained of in others, but there is great
vol. vi 29

450 LICHEN

chilliness. In one case after a duration of very many years soft ex-
crescences or tumours formed here and there over the body, in appearance
not unlike those of mycosis fungoides. Some of these broke down into
spongy ulcers, secreting a serous fluid, which only slowly healed. Others
after persisting for a time were absorbed. Though the patient was not
capable of much exertion his health was pretty good and his mind un-
clouded. It occurs both in males and females, and commences in adult
life. One cannot yet speak definitely of its termination. Like lichen
planus it seems not to attack the nails, but unlike it it involves the face
and scalp.

Pathology. — In relation to the pathology of lichen planus no micro-
organism has so far been held responsible for its causation. The special changes
are superficial, involving the epithelial layers, and mainly the papillary portion
of the corium. As already stated, the shape assumed depends very much on
whether the sweat glands, hair follicles, or the general tissue of the integument
are principally or wholly implicated. The morbid changes have been shown
by Torok to begin in the neighbourhood of the blood-vessels in the papillse,
of which oedema and cellular infiltration are an evidence. The oedema is a
solid one which flattens the papillae and forces them out of shape. The
burnish on the surface of the papules has been explained by Unna as due to
tension arising from the packing of the upper part of the corium with cells
and the coexistent swelling, but as Brooke points out there is also a modifica-
tion of keratinisation, since the polish is an early symptom, and persists even
when the papules have somewhat levelled down and distension from that
cause is reduced. The cells which crowd the tissues seem not to be in the
main leucocytes, but are chiefly derived from proliferation of the connective
tissue cells, and Walker regards them as similar in nature to those found in
the granulomata. The atrophy which in some cases succeeds the subsidence
of lichen may be quoted in support of this view. Pigment cells are met
with in the walls of the vessels before the disease has lasted long. The
white plugs visible in the centre of some of the papules are due to alterations
and thickening of the sweat pore, with loosening and separation, which
give rise to the depression. The white lines and network seen in their
structure arise from excessive development of portions of the granular layer,
which betrays itself by an opacity like ground glass. There is always,
increased thickness of the corneous layer, and this acquires extreme pro-
portions in the verrucous form. As retrogression proceeds there are
degenerative changes, shown by a colloid transformation and the increasing,
deposit of pigment.

Quite different is the morbid anatomy of pityriasis rubra pilaris. Here
the horny follicular papules are but part of a general hyperkeratosis. In-
deed, Unna holds that in its main features it approximates most closely to.
ichthyosis, and when one remembers that the slighter evidences of ichthyosis
are expressed in keratosis pilaris, there is good ground for the comparison.
The augmented keratinisation increases the surface area of the skin, and
thus it is thrown into folds of a coarse type, but there is but little infiltra-
tion into the papilke, which themselves are not swollen. The characteristic
papules are produced by the advance of the hyperkeratosis into the follicular
neck, but it extends into the deeper parts as well. Eeactionary changes in
the neighbourhood are indicated by a degree of local leucocytosis and inter-
epithelial oedema. '

Parakeratosis variegata is, as one would expect, closer to lichen patho-
logically. My own observations agree with those of Santi and Pollitzer that
the affection is limited to the epidermis and upper layers of the corium.

LICHEN 451

There is moderate dilatation of the vessels of the papillae and some oedema,
but the inflammatory phenomena proper are slight. There is interstitial
cedenia with dilatation of the lymph spaces in the prickle layer. The horny
layer is redundant and stretched, hence the degree of burnish. The appear-
ances in sections from one of my cases led a skilled observer, who was
ignorant of the source, to say that they were from a case of lichen planus.
There is therefore nothing surprising in the later development of granulo-
matous tumours.

Etiology. — Little definite can be said as to the etiology. It is true
that some of those affected are of the class termed neurotic, or have been the
subjects of worry or vexation ; but on the other hand it is fairly common
in well-nourished women about middle life, who are leading a placid and com-
fortable existence. It occurs about equally in either sex, may be met with in
children, though rarely, and much the same may be said as to its appearance
at the other extreme of life. It is certainly of more frequent incidence in the
better ranks of society, but it is found also in those who frequent hospitals,
who are, however, by no means necessarily, in Scotland at least, drawn
exclusively from the lower strata. It must be admitted, and this applies to
pityriasis rubra pilaris and to parakeratosis variegata, that we are absolutely
in the dark as to any determinate cause, an organismal origin is yet wholly
hypothetical.

Diagnosis. — The peculiar and characteristic features already described
must be mainly relied on. Though Hutchinson considers it as nearly
related to psoriasis, and mistakes in this direction are not very infrequent
among those, at least, who are not very familiar with a somewhat uncommon
ailment, still there are essential distinctions. The primary spot in psoriasis
is always scaly from the outset, while on enlargement the area is uniformly
so, or shows central involution, while the colour is different, and the itchiness
seldom so marked as in lichen. The papular variety of eczema is somewhat
like it, but the papules are more plainly red and are not glistening. They
become lost in the eczematous patch, and other vesicular, oozing, crusted, or
pustular forms are or have been present. Syphilis, however, does provide a
fairly close imitation, yet the small papular syphilide has a more coppery
tint, is more widely distributed, rarely forms patches, does not avoid the
face, is often mixed up with other types of eruption, and general con-
stitutional symptoms are discoverable as a means of discrimination.
The peculiar mottling with progression from above downwards, the slow
course with intractability to treatment, aid in excluding parakeratosis
variegata, and it is only when the encrustations have been removed by
oil packing or inunction that pityriasis rubra pilaris recalls lichen planus,
and then it is the rare lichen neuroticus that is simulated, hardly the
ordinary.

The prognosis in lichen is good ; at most the disease is obstinate, and from
the concurrent pruritus annoying, but ultimate recovery is the all but
invariable rule.

Teeatment. — In relation to treatment lichen planus is undoubtedly
capricious. The generalised form yields much more readily than that occupy-
ing restricted areas. The more rapidly it extends the more speedily does it
usually disappear, though months may be passed ere it finally vanishes.
The warty forms on the lower limbs are very obstinate. To get rid of it we
must avail ourselves both of constitutional and of local remedies. _ Arsenic
internally probably takes the first rank. It may be given either in pill or
in solution, and moderate doses should be persevered in for perhaps several
months ere it is abandoned as unsatisfactory. Should the itching be

452 LIFE INSURANCE

severe, strychnia may be combined with it, and if anaemia coexist, a not very
frequent circumstance, iron may be added. If arsenic fail or seem but
tardily effectual, antimony as recommended by Hutchinson is often an
efficient substitute. From eight to thirty minims of the vinum antimoniale
well diluted are to be taken three, four, or even for a period six times a
day. It commonly agrees perfectly, and only if it occasions sickness plainly
ascribable to it, or diarrhcea, should it be discontinued or the dose lessened.
If both are unsuccessful we may employ mercury, which in the form of the
perchloride has caused the disappearance of the disease. From the thirty-
second to the sixteenth of a grain twice a day with a grain and a half of
iodide of potassium gives the best results, any trace of salivation being
watched for, and obviated by temporary disuse and subsequent reduction of
the dose. Washing with menthol soap, or baths of Condy's fluid, an ounce
in a large bath at 90° to 95°, are useful for relieving the pruritus. Or the
following lotion of C. Boeck's may be freely used : R/ Talci, pulv. amyli,
liq. plumbi subacetat. dil., sol. acidi borici in aqua 1 per cent aa 100*0,
glycerini 40-0. When used this must be diluted with twice as much cold
water and painted on. In chronic, and especially in localised cases, coal tar
dissolved in acetone, as recommended by Sack, is advantageous. 1^ Picis
carbonis 10*0, benzol 20%0, acetone 77'0. M. In mild cases or in acute
forms a cleanly and valuable application is — Ify Acidi borici grs. 15, glycerini
amyli (1 in 16) unciam. In pityriasis rubra pilaris, baths of carbonate 'of
soda, two ounces in thirty gallons of water at 95°, followed by inunction
with vaseline, and combined with the subcutaneous injection of pilocarpine,
are indicated. For parakeratosis variegata no treatment has so far influenced
the disease.

LITERATURE. — Besnier. Annotations to French Translation of Kaposi's Text-book. —
Brocq. Traitement des maladies de la peau. — Brooke. Allbutt's System. — Crocker. Text-
book.— During, vox. Monats. f. prakt. Derm. Bd. xvi. 1893. — Fox, Colcott. Brit. Journ.
of Derm. July 1891. — Hebra. Text -book. — Hebra, Hans von. Brit. Journ. of Derm.
1890. — Hutchinson. Lectures on Clinical Surgery, 1878. — Morris, Malcolm. Trans. Int.
Congress. Rome, 1894.- — Neisser. Ibid. — Neumann. Archiv f. Derm. u. Syph. 1892. —
Walker. Introduction to Derm. 1899. — Wilson. Text-book. — Unna. Histo-pathology of
the Diseases of the Skin, 1896. — Monats. f. prakt. Derm. 1890. — Atlases: Crocker; Neu-
mann, St. Louis.

Life insurance.

Historical

Duties of Medical Man .

Family History of Proposer

Past History of Proposer

Present Health

Insurance has been defined as " a contract whereby one party, in considera-
tion of a stipulated sum, undertakes to indemnify the other against certain
perils or risks to which he is exposed, or against the happening of some
event." (From Marshall on Marine Insurance?)

It is difficult saying when insurance had its origin, but it is known that
it was in use in commerce in the fifteenth century, because an ordinance of
Barcelona refers to a contract of insurance. In all probability insurance was
a common practice in commerce before any laws on the subject were
recognised. Marine insurance was one of the earliest branches, and was
probably invented by the Jews and adopted by the Lombards. Life insur-
ance was only a branch of marine insurance.

452

Female Lives

463

454

Habits and Occupation .

464

455

Place of Residence

465

457

Age .

465

457

Tables op Expectation op Life

466

LIFE INSUKANCE 45:5

Life insurance was well known in the sixteenth century. At Genoa in 1588 wager
policies and insurances on the lives of public men were absolutely prohibited
without the leave of the Senate.

All life assurance was prohibited by Philip II. in 1570, and his example was
followed by other cities and states. The practice of insuring the lives of other
people was soon recognised to be a public danger. Grivel remarks : " These kind of
wagers are of sad augury and may occasion crimes." In 1753 Magens says "men
insured freely. In London people take the liberty to make insurances on any one's
life without exception, and the insurers seldom inquire much if there are good or
bad reasons for such an insurance, but only what the person's age is and whether
he be of a good constitution or not. The common premium on a good life from 20 to
50 years of age is 5 per cent, and from 50 to 60 years 6 per cent."

This insuring of other men's lives became such a crying evil in England that
the famous Act of 1774 was passed, prohibiting all insurances on lives in which the
person insuring had no interest. (Act 14 Geo. III. c. 48.)

The first insurance company was established in England in 1706 by a charter
of Queen Anne to Thomas Allan, the Bishop of Oxford, and others, and was named
The Amicable. Each member paid a fixed annual sum, and the surplus at the end
of the year was divided amongst the relatives of the deceased members. All were
admitted at a uniform rate, and members' ages on admission ranged from 12 to 45.
The Eoyal Exchange and London Assurance were empowered to carry on life
insurance in 1720. The Equitable was established in 1762, the Westminster in
1792, and the Pelican in 1797.

Insurance business has grown immensely during the nineteenth century. There
were 8 companies in existence in England before 1800. In 1824 there were 39 ; 105
companies were added between 1824 and 1844; 272 new companies were estab-
lished between 1844 and 1869. This rapid growth was partly due to the new
impulse given to the starting of new companies by the repeal of the Bubble Act
in 1825, and the passing of the Companies Acts of 1844 and 1862.

Many of these companies have ceased to exist. In 1880, of the 39 companies
established before 1824 all but one survived. Of the 105 established between 1824
and 1844, 38 had ceased to exist ; and of the 272 established between 1844 and 1869
only 29 survived.

It will be seen from the short history of life insurance just sketched that insurance
in the eighteenth century could hardly be said to have been based on a scientific
footing. From the quotation from Magens it will be seen that the rate of five
per cent was put on lives from 20 to 50, and six per cent from 50 to 60. This
haphazard way of imposing rates of premium resulted from a want of knowledge
of the rates of mortality amongst individuals of different ages.

At that time little was known of what is called expectation of life, although it
is true that the term " expectation of life " was used by De Moivre in the year
1725.

Simpson was in 1752 the first to arrange a table of expectations, but any tables
previous to the Northampton seem to have been based on hypothesis rather than
on statistics. The Northampton table of mortality was first given in a work on
annuity by Dr. Price in 1771, and for many years thattable was used by many of
the insurance companies. What is known as the Carlisle table was the result of
observations in two of the parishes of Carlisle, and published by Dr. Haysham in
1797, which observations were further elaborated by Mr. Milne. _ This table was
for many years recognised as the most accurate. In 1843 tables giving the results
of the experiences of 17 of the insurance companies were compiled, and these were
found to more nearly resemble the Carlisle than the Northampton tables. The total
number of policies made use of in the compilation of these tables was 83,905, of
which 44,877 were in existence, 25,247 withdrawn, and 13,781 had become claims
by death. The most striking results obtained were — 1st, the great mortality
amongst Irish lives ; 2nd, the marked difference in rate of mortality between
males and females ; 3rd, the near resemblance between town and country
experience. The mortality amongst insured females was greater than amongst
males.

In 1869 a still further advance was made in the statistics of mortality and. " ex-
pectation of life." A table was compiled by the Institute of Actuaries, which is
sometimes called The New Expectation table,1 sometimes the Institute of Actuaries'

1 The tables for convenience are designated in a particular way, H for healthy lives, D for
diseased lives, with a smaller letter above to denote the sex : thus, HM, healthy lives male ;
HF, healthy lives female ; HMF, healthy lives male and female. The HMF, the committee say,
may be fairly considered a standard table for life assurance.

454 LIFE INSURANCE

table. Twenty offices aided in the compiling of this table. The data were
ultimately published in four great divisions — 1st, healthy lives male ; 2nd, healthy
lives female ; 3rd, diseased lives, male and female ; 4th, lives exposed to extra
risk from climate, occupation, etc.

The assurance companies at first made very little attempt to select
healthy lives, at least no medical examination of the applicant was made,
nothing more than an inquiry as to whether he was in good health. A
medical man at first was not recognised as necessary. As recently as 1815,
according to the form of the Scottish Widows' Fund Society, all that was
necessary was that the applicant should appear before a medical man, who
certified that he was apparently in good health, and that he had never
suffered from gout, asthma, or any other disease which shortened life.

About 1830 this society required a certificate from the medical attendant
of the applicant, and a series of questions about his health and habits had
to be answered. About the same time the office appointed their own
medical adviser, who helped the manager and directors to select the lives.
The society also required certificates as to health and character from
private friends of the applicant. In 1835 all applicants had to appear
before the medical adviser of the company as well as to have a series of
questions answered by their own medical attendant. The agent and two
friends had also to give a report on the life (Muirhead).

This is practically the method of selection adopted by most of the best
insurance companies at the present day, with the exception that it is only
in cases where a report from the medical attendant of the applicant may
throw more light on his family and previous history, that a special report
from the medical attendant is called for.

It seems to be pretty generally recognised that the insurance companies
have in The New Experience tables a fairly accurate estimate of the expecta-
tion of life of healthy persons at different ages, and that the premiums that
the insured have to pay are fair both to the insurer and the insured, when
the insured is what is called an " average life."

But when under average lives come to be considered, the problem as to
whether such lives ought to be " loaded " with an extra premium, and how
much " load " is to be put on, is one of great difficulty, and one which has
given rise to much discussion. Some have maintained that the benefits of
a medical examination of the applicants are lost in a very few years. It is
unnecessary to enter into all the arguments which have been used in favour
of this contention, but it has been as strongly maintained, on the other
hand, that although much of the benefit is lost after the first few years
still the influence of selection is felt even in the older policies.

The task before a medical examiner for an insurance company is, there-
fore, to determine whether the life of the applicant for insurance is an
average healthy life having average expectation of life, or an under average
life having an expectation of life below the average — and if the latter,
whether the life can be " loaded " to such an extent that such loading would
be fair both to the insured and the insurer.

Statistics of under average lives have, of course, been prepared, but much
yet requires to be done in order to accurately determine what amount of
" loading " is necessary in any particular case. If a case of valvular disease
of the heart be taken as an example, the question might be asked, Is the
expectation of life of such an individual lower than that of one with no
valvular disease ; and if so, how much ? Most medical men will agree
with Sir Wm. Gairdner in the opinion that a large number of cases of
valvular disease live to a good old age and far beyond what one would

LIFE INSURANCE 455

expect. Actuaries say that this does not affect the general fact that cases
of valvular disease, when taken altogether, have on the average a lower
expectation of life, and they point out that expectation of life does not
mean the probable duration of life of each individual, but the average
duration of life of a large number of individuals. This, of course, is quite
true, but the problem before medical men is to determine what are the
factors in each case which makes a life an average one or an under average
one. The advance of medical science added to the experience of insurance
companies will probably help us to solve these difficulties, and enable us to
arrive at a more accurate estimate of the amount of loading required in
particular cases.

In determining whether an applicant is eligible for assurance and at
what rate of premium there are certain factors which the medical advisers
of the company have to consider and give due importance to. These factors
may be classed under different heads — 1st, the family history of the pro-
poser ; 2nd, the past history of the proposer ; 3rd, his present state of
health ; 4th, his habits and occupation ; 5th, his place of residence ; 6th, his
age.

The lists of questions which have been drawn out by the various insur-
ance companies to be put to the applicant, to their agent, to the applicant's
personal friends, and to the medical examiner, are intended to elicit all
necessary information on these points, and the medical adviser of the com-
pany ought to have all such information before him at the time of his
giving his opinion as to how a life is to be classed. Insurance companies
vary as to the classification of lives, but all lives can be conveniently classed
under three groups : — 1st, (a) Lives probably above the average insurable at
ordinary rates ; (b) Average lives insurable at ordinary rates. 2nd, Under
average lives insurable with a certain amount of " loading." 3rd, Under
average lives not insurable.

To determine in which group a life is to be classed all the factors before
mentioned have to be considered and weighed.

1. Family History. — Although at the present day the belief in the
hereditary transmission of disease is not by any means so general among
the medical profession as it used to be, still few will dispute the fact
that some families are liable to certain diseases, and if the diseases them-
selves are not hereditary the liability to these diseases runs in families.
Consumption, which was considered one of the most hereditary of all
diseases, is now believed not to be transmitted at all from parent to
child — yet it can hardly be denied that consumption runs in families.
Although, therefore, opinion has changed as to why certain diseases are
more prevalent in some families than others, there can be no denying
the fact that they are, and it is therefore necessary for insurance com-
panies to inquire into the family history of the applicant for insurance.
It is necessary, in the first place, to ascertain whether the applicant's
father and mother are alive or dead. If alive, in what state of health
and what their ages are ; and if dead, at what ages they died and what
was the cause of death. The number, state of health, and ages of the pro-
poser's brothers and sisters should also be ascertained ; and how many, if any
are dead, their ages at death, and causes of death. In many cases, of course,
the family history is quite satisfactory, but in some there are facts which
at once arrest attention. The family may be all short or long lived, because
there can be little doubt that some families seem to have a greater tenacity
of life than others. If all or several members of the family have been
short-lived the causes of death will probably indicate what disease or

456 LIFE INSURANCE

diseases the family is liable to. If, for instance, two or more members of a
family of six or seven had died or suffered from tuberculosis, one would be
suspicious that the family had a tendency to contract that disease, and it
would be advisable to make further inquiries as to tubercular disease
amongst the more distant relations of the proposer, such as the uncles, aunts,
cousins, grandfather, and grandmother. This is more especially necessary
where the proposer's immediate relatives are few in number. The prevalence
of any particular disease in the family should also be followed by a searching
examination of the individual, especially as regards the particular organ or
organs liable to be affected by that malady, to ascertain whether the pro-
poser is free from disease, and is constituted in such a way as not to be
likely to develop it. In the case of consumption, for instance, particular
attention should be paid to the form, movements, and development of the
chest, as well as to whether the lungs are healthy. The habits of the
individual as well as his occupation would here also be of considerable im-
portance in determining whether he was likely to develop the disease.
The age of the proposer in a case of this sort is of great importance. If
young and under the age at which his relations died, his life is not so good
a one as if he had passed middle life, or had well passed the age at which
the relatives died. This, of course, applies to consumption, but each disease
has to be specially considered, as it is well known that the age at which
different diseases manifest themselves varies greatly. Whilst, for instance,
pulmonary phthisis is most prevalent from 18 to 30, gout, cancer, insanity,
paralysis, etc., are more apt to prove fatal in later life. The bearing of these
facts on the expectation of life of an applicant for insurance who has a
family history of those diseases is self-evident.

But the question for an insurance examiner is whether an individual
case before him with its own particular family history should be admitted,
and at what rate, or rejected. Can any rule be laid down as to what con-
stitutes a family history showing a tendency to a particular disease ? In
answering this question, much, I think, must depend on the disease which is
under consideration. The mere presence of a case of consumption, a case of
gout, a case of paralysis in some near relative of the proposer, can hardly be
taken as showing a tendency to any of those diseases, and yet if any of the
near relatives have suffered from any of the so-called hereditary diseases
the medical examiner must necessarily be on the look-out for evidences of
the same or allied diseases in the proposer. Dr. James Begbie, in his reports
to the Scottish Widows' Fund Society, was the first, I believe, to lay down
the rule that the presence of two undoubted cases of consumption in near
relatives of an applicant for insurance should be an absolute bar to his being
admitted. This view was later very strongly advocated by the late Sir
Bobert Christison in his report to the Standard Insurance Company, and
later still . by the late Dr. Warburton Begbie, and probably most medical
examiners at the present day would adhere more or less to this view,
especially where the age of the proposer is under 30 years. It might, how-
ever, become a question for discussion whether such a life might not be
accepted at least with an extra premium, if he himself was in good health
and over 30 years of age. The farther he had passed 30 the less risk there
would be to the insurance company.

Ought the same rule to apply to gout, rheumatism, cancer, insanity,
paralysis, etc. ? Most medical examiners would probably not go so far as
this. They would probably seek for some evidences of these or associated
diseased conditions in the proposer himself before rejecting him altogether,
or even recommending his acceptance at an increased rate. Each disease

LIFE INSURANCE 457

has therefore to be considered separately, and the points to be considered
in regard to it are : 1st, Its liability to manifest itself in successive genera-
tions. 2nd, The age at which it is most likely to appear. 3rd, The effect
the disease or constitution has on expectation of life. 4th, The kind of
insurance proposed — whether endowment or whole life. These will be best
considered later in connection with the particular diseases.

2. Previous History of the Proposer. — The previous history of the
proposer often gives much information bearing on the question of his
expectation of life to the medical examiner and to the insurance company.
His past history may indicate what is his constitutional diathesis, and
also whether he has had any disease that is likely to have left him weak
or more liable to the onset of other diseases. For instance, a history of
acute rheumatism in the early life of the proposer would indicate, not
merely the existence of the rheumatic diathesis, but would also clearly call
for a special examination of the condition of the heart. Similarly with
scarlet fever, an examiner should naturally specially look for sequelae of
that disease, such as enlarged glands, otorrhoea, cardiac disease, and kidney
mischief. The previous history of the proposer is therefore more of
importance as a guide to the examiner where to specially examine for
any weakness which may have developed as a result of past illness, than
as an indication as to whether the proposer is to be admitted or rejected,
because I take it that there are very few cases where the past history alone
would cause the rejection of the life if no trace or result of the past illness
was found at the time of the medical examination.

3. Present State of Health of the Proposer. — The state of health of the
proposer at the date of his examination must necessarily be the most
important of the factors in determining whether the proposer is a healthy
life or not. A careful examination must therefore be made of all his
organs with the object of finding out not only how they are at present
performing their functions, but whether there is any trace of abnormality
or defects produced by previous illness or habits. Mere questioning of
the individual is not sufficient, as he may not be aware of some very
important weakness in his organisation, such as the presence of organic
heart or kidney disease. The general appearance often gives very im-
portant information as to his state of health. Such general appearance
when taken along with the family history may indicate whether the life
is a good one or not, even such details as the complexion, and whether
the proposer resembles more closely his father or his mother, being of
importance. The weight of the proposer should always be noted and
compared with the height. When a person is much over weight his
expectation of life is not so good as that of a person of about normal
weight. In the same way a person under weight, and especially markedly
under weight, is either already affected with, or is in a condition in which
he is more liable to the onset of disease. The family history, the previous
health, and the constitutional diathesis of the individual, should all be
considered along with the weight. Under-weight, for instance, may show
a tendency to tubercular disease ; whilst over -weight may point to a
tendency to gout, to stomach and liver troubles, and also may give some in-
dication of the habits of the individual. The following table of Hutchinson's
gives the average relation between the height and weight of an adult man : —

Height 5 feet 1 inch. Weight 120 lbs.

„ 5 „ 2 inches. „ 126 „

„ 5 ,, ,j ,, ,, 133 ,,

„ 5 „ 4 „ „ ] 39 „

n 0 ii 5 ii ii 14J ,,

458 LIFE INSURANCE

Height 5 feet 6 inches.

5 ,

, 8 „

5 ,

, 9 »

5 ,

» 10 „

5 ,

, 11 »

6 ,

jig

ht 145 lbs

?»

148

155

162

168

174
178

55
35

An approximate method of arriving at what the weight of a person
ought to be, is to take the cube of his height in inches and divide by 2000,
the result is what the weight ought to be in lbs. For instance, a person
of six feet by this method ought to be 186 lbs. in weight. One-seventh
either above or below this may be quite consistent with health (Maclagan).

Eapid changes in weight should always be looked upon with suspicion.

Deformities, such as spinal curvature or other changes indicating
diseases of bone, should be specially noted, and particular attention paid to
whether the disease which caused such deformities was still active or
quiescent. Whether the proposer has been vaccinated and revaccinated,
or had small-pox, are important points.

Respiratory System. — Probably diseases of the respiratory system are
responsible for more of the deaths of insured persons than those of any other
system in the body. Of the diseases of this system the most important
are phthisis, bronchitis, asthma, pneumonia, and pleurisy. A person
actually suffering from any of these diseases should, of course, be rejected
by the medical examiner, although it might be quite possible for the
same proposer to be admitted after he recovered from the last four
diseases, provided his family history was favourable and his recovery
complete, but it must always be kept in mind that a person who had one
of these diseases is probably more liable to another attack, and especially
is more liable to the onset of phthisis. This is more especially the case
with regard to pleurisy, and therefore a candidate for assurance who has
once been affected with pleurisy should be subjected to a very searching
examination for the remains of the disease or the early traces of phthisis.
So with bronchitis and asthma, and also with pneumonia, although probably
in a lesser degree. But phthisis is by far the most important of the
diseases of the respiratory system, and in spite of the fact that insured lives
are selected and submitted to an examination of the chest when admitted
to insurance, in the words of Sir Eobert Christison : " Consumption is of all
single diseases the most important in relation to life insurance."

The statistics of insurance companies show how important it is for
the insurers to reject all lives likely to be affected with consumption. They
are in most cases a loss to the companies. The figures also show that the
companies derive the benefit from selection for at least some years after
the lives are admitted. This is the explanation of the fact that a large
number of insured consumptives survive to a comparatively late life for
consumptives. The figures of the companies bring out another fact,
that very few of the cases insured above 40 years of age die from
consumption, showing that if persons remain healthy till 'middle life
they are not nearly so likely to be affected with consumption. This is
a fact of very great importance when the proposer has a family history
showing a predisposition to consumption. Experience shows that if
proposers have reached 30, and still more so 35 or 40 years of age, or if
they have well passed the age at which their relatives died or suffer from
the disease, there is much less risk in accepting their lives for assurance.

When there is a suspicion of a tendency to consumption in a candidate,
the general development and expansion of the chest during respiration

LIFE LNSUKANCE 459

ought to be carefully noted, as well as the weight and the pulse-rate. An
abnormally high pulse-rate is often an early indication of the onset of
the disease. Weak digestion and disturbances of the digestive organs
generally also often precede the onset of more evident symptoms.

The late Sir Eobert Christison, in discussing this question, made the
following statement, and it is doubtful whether our knowledge at the
present day could enable us to alter it much in any way. He stated :
" General delicacy — a state of health described as ' tolerably good,' or
' pretty good,' or ' not robust,' a great liability to ' slight common colds,'
or ' rheumatic pains,' or ' bilious complaints,' a pulse habitually frequent,
are all suspicious circumstances in one whose family has suffered at all
from consumption. Among these particulars I would call attention
especially to a liability to indigestion as a serious ground of doubt when only
one member of a family has been cut off by consumption. Either frequent
indigestion favours the development of consumption in the predisposed by
further impairing a previously doubtful constitution, or simply the two
liabilities may be each the direct result of the same constitutional defect."

Proposers with actual symptoms of chest disease cannot be accepted as
healthy lives. Whether such can be admitted when the attack has been
well passed, will depend on whether the recovery has been so complete as
to leave no trace behind it, on the family history, and on the habits and
occupation as well as the other circumstances of the individual.

Heart and Circulatory System. — The question of heart disease in
relation to life assurance has given rise to much discussion, but I doubt
whether we have yet much evidence to guide us as to which lives affected
with valvular disease of the heart ought to be accepted, and which ought
to be rejected. There can be little doubt, as pointed out by Sir William
Gairdner and others, that some diseases of the heart live to a good old
age — and many medical men will also admit that a heart murmur which
is distinctly present may in the course of time entirely disappear.

In spite of these facts, we have not yet got sufficient data to guide
us in arriving at the most important decision for the insurance companies,
viz. which are most likely to live to a good old age, and which heart
murmurs are most likely to disappear, leaving the heart in a healthy
condition. The time may come when we will be able- to classify lives
with cardiac lesions, so that those most likely to live to an old age can
be picked out from the others, but I am afraid at the present time our
medical knowledge does not enable us to go so far. The presence of a
cardiac murmur indicating organic disease of the heart must, therefore,
be taken as a very important factor in deciding whether a life is in-
surable as an average life or not. Whether such a case can be admitted
at an increased rate of premium must depend to a great extent on the
circumstances of the proposer. In justice to the companies, probably it
would be better to reject all such cases ; but there may be circumstances
where the risk to the company in accepting those lives would be limited.
The experience of the companies has shown that cases of heart disease
die not in the earlier, but in the later part of the insured period. These are
of course selected lives, i.e. lives presumably free from heart disease on
admission to insurance, and conclusions drawn from these statistics alone
are liable to many fallacies. If a proposer with a cardiac murmur is to be
admitted to insurance at all, the "loading" should be a heavy one, and
it would be safer for the company to have the insurance in the form of an
endowment insurance, payable at a certain age, as far below 60 as possible.

In the examination of the circulatory organs the past history of the

460 LIFE INSUKANCE

proposer and his family history ought to be carefully inquired into, with
the object of finding out any traces of the rheumatic or gouty diathesis,
both of which are well recognised to be associated with diseases of the
heart and blood-vessels. The pulse should be carefully noted, not only as
to its rate, but more carefully as to the state of the vessel wall for any
trace of degeneration of the blood-vessels.

Thickening of the arterial walls is an important symptom, and ought
to debar a life from being accepted. The presence, of course, of even
more serious vascular wall mischief, such as aneurysm, makes the risk too
serious a one for the company to accept the proposal. As is well known,
vascular degenerations are often the result of an attack of syphilis, and
therefore a previous history of this disease is of considerable importance.

A too rapid or too slow pulse are suspicious symptoms, the first because
it may indicate the presence of other diseases such as consumption, as
well as a disturbance of the nervous mechanism of the heart's action,
the latter because it is often associated with serious degeneration of the
heart muscle. It must not, however, be forgotten that both are to a
certain extent consistent with health, and that the former may be
produced by nervousness (" the insurance heart "). A past history of
rheumatism, of scarlet fever, and of chorea should make the examination
more searching, because they are so apt to be associated with endocarditis
and disease of the heart. The presence of pericarditis or a pericardial
murmur should at least cause the postponement of the insurance. Many
such murmurs entirely disappear, and although, therefore, it would be too
great a risk to accept a candidate with a pericardial murmur, the same
life might be accepted later at the usual or an increased rate. So also
with a case having a murmur which is believed to be anaemic in origin.
Such a proposal should be postponed and the candidate should be submitted
to an examination later on in order to ascertain if the murmur has
actually disappeared with the disappearance of the anaemia.

Examination of the Organs of Digestion. — Inquiries ought to be made
as to the presence of indigestion, bilious attacks, constipation, or diarrhoea,
as indicating whether the proposer is in robust health or not. I take it
that the mere presence of occasional indigestion alone is not sufficient to
reject a proposal, but a history of indigestion may indicate the presence
of a serious disease such as gastric ulcer, cancer of the stomach or liver,
or cirrhosis of the liver, any one of which would render the life uninsurable.
Physical examination of the abdomen should never be omitted, the size
of the liver and spleen being noted.

Habits as to drinking and eating should be specially inquired into in
this connection. It is well known that intemperance and the habitual use
of alcohol to excess leads to disorders of the stomach and liver, especially
to cirrhosis of the latter organ. A history of repeated attacks of appendi-
citis makes the life a more risky one unless the appendix has been
removed by surgical operation.

With regard to hernia, all the best companies require a declaration from
the proposers that if ever they have rupture they will constantly wear a
well-fitting rupture truss. The wearing of such a truss reduces the extra
risk in such cases to a minimum.

The presence of an abnormal amount of adiposity is an important factor,
but this has already been referred to under height and weight. The
presence of dropsy indicates some serious cardiac liver or kidney disease.

State of the Urinary Organs.- — Formerly the insurance companies only
insisted on examination of the urine in cases where the examiners were

LIFE INSUKANCE 461

suspicious of kidney disease, but all the best companies now require a
report of the result of the usual tests for abnormalities. The specific gravity,
the reaction, and whether there is present albumin, sugar, or other abnormal
products, should be noted.

A very high or very low specific gravity may raise the suspicion either
of diabetes or Bright's disease, and further tests may or may not confirm the
suspicion.

Undoubted cases of diabetes or Bright's disease are uninsurable. The
presence of sugar in any considerable quantity in the urine of young lives
must always be taken as an indication of true diabetes mellitus, and therefore
a bar to insurance, but it is well known that in persons past middle life the
presence of a small quantity of sugar in the urine is not such a serious
matter, although it almost invariably occurs in persons of a gouty diathesis.
Such cases, however, are more to be reckoned as cases of gout than of true
diabetes, and are to be considered more from the gouty point of view than
from that of diabetes.

The mere presence of albumin in the urine is not now considered to be
such an invariable indication of Bright's disease of the kidneys as it used to
be. It is well known that persons apparently in good health may have
albumin present in their urine, at least temporarily. The presence of tube
casts in the urine along with the albumin points very clearly to Bright's
disease, but in cases where no indication of Bright's disease other than the
presence of albumin in the urine is present, it is rather difficult deciding
whether the life ought to be accepted or not. The urine of such cases,
passed at different times in the day, should be examined on various occa-
sions to ascertain whether the albumin is constantly present or not.
Sometimes the albumin may be — (1) Paroxysmal, i.e. it occurs at intervals
separated by considerable periods during which there is no albumin present.
(2) It may appear only after certain articles of diet. (3) It may appear after
muscular exertion, the urine being normal when the body is at rest. (4)
The urine may always be albuminous, but the albumin is in small quantities
and not influenced by food or exercise. It is difficult being definite as to
how such cases ought to be treated by insurance companies. True
paroxysmal albuminuric cases ought not to be loaded to any great extent,
if at all, but if albumin is constantly present even in persons otherwise
apparently healthy a certain amount of loading should be imposed, and in
some cases, where the life otherwise has something unfavourable, such as a
family or personal history of gout, the life should be rejected.

Albuminuria is often associated with the gouty diathesis, and the presence
of albumin in the urine of persons of sedentary habits, such as those who
lead a confined life in the city with little exercise and good living, is often
associated with other crystalline deposits in the urine and troubles of diges-
tion. Dr. Hingston Fox states that such cases may be accepted unless the
albumin is very abundant or the crystals very large, in which case treatment
becomes necessary before acceptance. Dr. Bewley's opinion is, I think, a
safer one, viz. "that the inactive habit of life, over -eating, and gouty
tendency noted in these cases prevent us looking on them as first-class lives."
In addition to these different causes of albuminuria there may be albumin
present in the urine from heart disease, and after fevers, as, for instance, scarlet
fever, diphtheria, and accidentally from discharges into the urinary passages.
In the first the heart disease would render the life uninsurable. In the second
the proposal should be postponed for six months or a year to ascertain
whether the albumin is permanent, and in the last cases the nature and
source of the discharge would decide whether the life was insurable or not.

462 LIFE INSURANCE

Diseases of the Nervous System. — Most of the organic nervous diseases
render lives uninsurable. The most common diseases of the brain and
spinal cord are those which come on in later life, such as paralysis due to
hemorrhage, embolism, and thrombosis, and are usually associated with
degenerative changes in the heart and blood-vessels. They are one of the
most fruitful causes of death in later life, and hence candidates for assur-
ance after middle life should be specially examined as to the state of their
vascular system, and in this connection a history of gout and rheumatism
is of great importance. A distinct history of insanity in a family should
also be looked upon as an unfavourable factor in a life, and in this connec-
tion a history of intemperance in the family and in the individual should
be specially inquired into, and considered along with the habits and occupa-
tion of the proposer.

How candidates for assurance with suppurative disease of the middle ear ought
to be dealt with has been much discussed. The consensus of opinion of the many
specialists who took part in the discussion of this subject at the British Medical
Association meeting in Edinburgh in 1898 seemed to be that there are some cases
which should be admitted at ordinary rates, or with a slightly increased premium,
and some should be rejected.

Cases of old -standing suppuration, where the discharge has completely or
almost completely ceased with no attacks of pain, may be admitted at the usual
rates. Cases where there is a fair- sized perforation, with little discharge and no
attacks of pain, may also be admitted at the ordinary rates.

In judging of the amount of risk, attention should be paid to the size and
situation of the perforation in the membrane. If small and high up, the risks are
greater. If the discharge is copious and foetid, the risks are also greater (M'Bride).

Cases where there are granulations or polypi, or where there is a small perfora-
tion and offensive discharge, should not be admitted without special treatment.
If the result of the treatment is satisfactory the proposal may be admitted at an
increased or even the ordinary rate, according to the degree of improvement in the
condition. In cases having a recurrence of attacks of pain the proposals should
be rejected.

Where there is evidence of the existence of suppuration in the mastoid cells,
or of caries or necrosis of the bones in any part of the ear, or where there are
exostoses or cholesteatomata of the middle ear interfering with free discharge, pro-
posals should be rejected.

In cases of suppuration with facial paralysis the proposal should not be
entertained.

Where there is acute suppuration the proposal should be delayed until the
result of treatment is seen. In cases where there is a family history of tuber-
culosis, the presence of middle ear suppuration should be looked on as an
unfavourable factor.

General Constitutional Diseases. — The most important are rheumatism,
gout, and syphilis. The first two I have referred to in connection with the
various organs. A distinct family history of rheumatism and of gout should
be looked on as unfavourable factors, and if these diseases in addition have
manifested themselves in any way in the proposer the life should either
be loaded or rejected altogether according to the form in which he has been
affected.

His rejection will depend on whether his organs have or have not been
affected by the disease. Whilst, therefore, a rheumatic individual would be
rejected if he had a heart murmur, if that organ had escaped his life might
be accepted with or without a load in special cases. The question of the
loading of cases showing a gouty history has been much discussed. It is the
custom of the companies to impose an extra premium for gout, but accord-
ing to Meikle (" Gout as a Eactor in Life Assurance," Brit. Med. Journ. 1898,
vol. iii. 764), the extra they have been in the habit of imposing is too little
to cover the risk. His observation was based upon 525 lives charged an

LIFE INSUKANCE 463

extra premium because of their lives being affected by gout. He ascertained
the number that entered upon each age of life, and computed the number
that were expected to die at these ages according to the experience of
healthy lives. The number calculated to die according to this standard was
120. The actual number who died was 160, or an increase of 33 per cent.
This increased mortality with one exception pervaded the whole of life.

These figures are very striking as well as the other tables in Meikle's
paper, but exception might be taken to them because of the indefinite way in
which cases are sometimes classed as gout. As an extra premium had been
imposed, and had been paid by these cases on account of gout, in all probability
most of the cases were very decidedly gouty. What difference the inclusion
of cases where family history and personal condition showed only a trace or
mild degree of gout not taken note of would have made on these figures it
is impossible to say, but the mortality in all probability would have been
somewhat reduced. The indefinite nature of slight symptoms of gout
makes it very difficult getting reliable statistics on the subject. Meikle
traced the cause of death in the 160 gouty persons, and classified them as
follows : — He first deducted 63 who died from various miscellaneous diseases,
and found that 42 per cent died from affections of the brain, 26 from
affections of the heart, 11 per cent from gout, 11 per cent from affection of
the kidneys, 10 per cent from natural decay.

Syphilis. — A candidate for assurance with primary, secondary, or tertiary
symptoms of syphilis should not be admitted as a healthy life, and his
proposal.should, if not absolutely refused, be postponed till all symptoms and
results of the disease have disappeared, when, if the case has been properly
treated, it may be admitted at an increased rate. There is, however, little
doubt that many syphilitic cases show symptoms of the disease many .years
after all symptoms have temporarily disappeared, whilst others never have
the slightest return of the disease. Careful inquiry as to the history, the
method of treatment, and the progress of the symptoms, should aid the
examiner in deciding as to the admission or rejection of individual cases.

Cancer. — Cases of cancer are uninsurable. Whilst one case of cancer
in a family may not affect the life, the fact that a proposer's father and
mother both died of cancer should be looked on as an unfavourable factor.
Endowment insurances are preferable in such cases.

Female Lives. — If the candidate for assurance is a female the examiner
has to pay special attention to the functions of the female generative organs,
and special inquiries must be made to discover whether menstruation is and
has been regular and physiological.

The presence of disease of the uterus, Fallopian tubes, or ovaries makes the
life not so good a one, and may require a special report. In married women
information may be elicited from inquiries as to the length of time married,
the number of pregnancies, the number of children alive and their state of
health. In this connection the difficulty of the labour and the rapidity of
recovery from her confinements are of great importance, especially in cases
where the proposer is actually pregnant at the time of examination.

What amount of extra ought to be imposed for pregnancy has been
much discussed, chiefly because of the great difficulty in getting reliable
statistics on the subject. In a paper by Playfair and Wallace, read at the
British Medical Association meeting in Edinburgh in 1898, giving the
results of their investigation into the statistics of the Eoyal Maternity,
Edinburgh, they arrived at the conclusion that the uniform rate that the
companies are in the habit of charging for pregnancy was in many cases
too low. Their conclusions are the following : —

464 LIFE INSURANCE

1. For the uniform extra premium at present charged, an extra premium
varying in amount according to age should be substituted.

2. The extra premium for a first pregnancy should be at least three
times as great as that for a subsequent pregnancy.

3. A proposal from a woman aged 30 or upwards pregnant for the first
time should be delayed.

4. A proposal for insurance from a pregnant woman aged 40 or
upwards, whatever the number of pregnancy, should be delayed.

The figures of a Maternity hospital can hardly be taken as the average
for a community, and especially as the average amongst female lives which
are likely to be insured. The worst cases of the lower class community are
apt to be attended by the maternity medical officers for many reasons. The
out-door cases are in the most insanitary houses ; that class of the community
only engage and send for doctors when the labour is expected to be a severe
one, most of the ordinary labours being attended by midwives, or other
women with more or less experience, and many of the cases are unmarried
females. Although the maternity figures are interesting they cannot be
accepted as conclusive. In cases where the candidate is actually pregnant
it is safer for the companies to postpone the insurance if possible till after
the confinement, but where this cannot be done, and it is necessary to
have the insurance completed at once, a special loading-rate on the lines
of the above conclusions may be imposed.

4. Habits, Occupation, etc. — The habits and occupation of the proposer
have already been alluded to in various connections. The question of
temperance in eating and drinking is one of special importance, especially
when considered in connection with a family or personal history of gout,
rheumatism, or intemperance. It will at once be seen how important also
the] occupation of the individual is in this connection. A person whose
occupation exposes him constantly to the temptation of "nipping," or
taking alcohol frequently, although in small quantities, is very apt to be-
come more and more intemperate, and to develop other diseases as the result
of his alcoholic habits. It was long ago shown (Registrar- General's Report
for 1851) that persons whose occupation exposed them to such temptations
died at an earlier age than the average of the community. As long ago as
1876, Stott, from the experience of a well-known company for fifty years,
arrived at the conclusion that the mortality amongst publicans and inn-
keepers, and those connected with the retail liquor trade, was 63 per cent in
excess of the Carlisle table, and 68 per cent in excess of the Actuaries' table.

He also concluded that the practice of imposing an extra rate of £1 per
cent in this class was necessary, but sufficient to cover the risk. A joint
inquiry which was made by the Scottish Life Offices into the mortality of
the same class of persons brought out much the same results. The following
table shows the annual mortality per cent at the different ages as compared
with the ordinary assured lives : —

Annual mortality per cent.

30
40
50
60

blicans.

Other persons.

1-48

0-77

2-59

1*03

3-08

1-60

4-59

2-97

The actual deaths exceeded the expected by 83 per cent, the actual deaths
being 430, and the expected only 235.

With reference also to habits, it is well known that people who lead an
out-door life in the country are healthier than those of more sedentary

LIFE INSURANCE 465

habit, and especially if the latter are shut up indoors in town. The family
and personal history have to be considered along with the habits and
occupation. A person having a tendency or predisposition to gout is more
liable to suffer from the disease if he has sedentary habits, little exercise,
and little outdoor life ; and in the same way a person with a family history of
phthisis is more likely to escape the disease if he lives an outdoor life,
with enough exercise and no unhealthy surroundings. On the other hand,
if such an individual has an occupation where the air he breathes is con-
taminated with dust or other impurities, or if he is engaged in an office
sitting over a desk where his lungs do not get properly expanded, and he is
unable to get sufficient exercise, he is much more likely to become affected
with the disease.

It is well known that some occupations are more healthy than others,
and many statistics have been collected showing the rate of mortality among
different classes of the community. The figures of Dr. Bertillon in France
and of Dr. William Ogle in England bring out practically the same result.
They show the enormous mortality amongst certain workers. According to
Ogle, if clergymen be taken as the standard and represented by 100, then
the mortality may be represented as 169 among commercial clerks, 108
amongst gardeners, 114 amongst farmers, 158 amongst shopkeepers, 189
amongst tailors, 143 amongst fishermen, 267 amongst cabmen, 160 amongst
coal-miners, 222 amongst quarrymen, 211 amongst butchers, 300 amongst
file makers, 229 amongst scissors makers, 314 amongst earthenware makers,
397 amongst inn and hotel servants, etc.

5. The -place of residence of the individual insuring has to be considered
by the insurance company, as it is well known that some countries are
healthier than others, and the death-rate of different countries varies. In
tropical countries the inhabitants do not live so long as they do in temperate
climates, and this applies more especially to Europeans who reside in
tropical countries. Michael Levi made the calculation that there is 1
death annually amongst every 25 of the population from the equator to the
20th degree of latitude, 1 in 35 from the 20th to the 40th latitude, 1 in 43
from the 40th to the 60th, and 1 in 50 from the 60th to the 80th. The
death-rate among Europeans in the tropical and subtropical regions is prob-
ably greater than these figures indicate, but much depends on the elevation
of the country as well as its sanitary conditions and freedom from special
diseases such as malaria. High table-land is healthier for Europeans than
low-lying districts, and much therefore depends on the configuration of the
country. Companies are in the habit of imposing a certain increase of rate
for those insured who reside in tropical or unhealthy climates, such as
tropical Africa and the East and West Indies.

6. Age of Proposer. — This, of course, is one of the most important for the
insurance company to ascertain because the expectation of life of healthy
persons is calculated from the age.

Many expectation of life tables have been framed to show what the
average expectation of life of persons is at different ages. These tables
have already been referred to, but as they are of great importance I here-
with give the Carlisle table alongside of the Institute of Actuaries' new
experience tables. The first was based on calculations of the deaths in two
parishes in Carlisle during several years at the end of last century, the
latter was the experience table of twenty insurance companies compiled in
1869. These tables are used by the insurance company as the basis for
calculating the rate of premium to be paid by each policy-holder, the
amount of premium per cent varying according to age.

VOL. vi 30

466

LIFE INSURANCE

Expectation of Life according to the Carlisle and
Institute of Actuaries' Tables.

"Age.

Carlisle.

Actuaries.

Age.

Carlisle.

Actuaries.

HMF

38-7

68-4

55-5

57-6

27-0

26-7

27-6

26'8

44-7

57-4

54*5

56-6

26-3

26-8

27-0

26-1

47-5

56-4

53-5

55-6

25-7

25-2

26-3

25*4

49-8

56-3

52-5

55-1

25-1

24-5

25-6

24-7

50-8

55-3

53-0

54-8

24-5

23-8

25-0

24-0

51-2

54-3

52-0

53-8

23-8

23-1

24-3

23-3

51-2

53-8

51-0

53-1

23-2

22*4

237

22-6

50-8

53-1

50-9

52-7

22-5

21-7

23-0

21-9

50-2

52-1

49-9

51-7

21-8

21-0

22*3

21-2

49-6

51-1

49-2

50-8

21-1

20-3

21-6

20-5

48-8

50'3

48-2

49-9

20-4

19-6

20-9

19*8

48-0

49*5

47*3

49-4

19-7

19-0

20-2

19-2

47-3

48-7

46-5

48-4

19-0

18-3

19-5

18-5

46-5

47-9

45-8

47-5

18-3

17-6

18-9

17-8

45-7

47*0

45-1

46-6

17'6

17-0

18-2

17-1

45-0

46-2

44-3

45-9

16-9

16-3

17-5

16-5

44-3

45-3

43-6

45*1

16-2

15-7

16-9

15-9

43-6

44-4

42-9

44-2

15-5

15-1

16-2

15-3

42-9

43-6

42-2

43-4

14-9

14-4

15-5

14-6

42-2

42-8

41-5

42-6

14-3

13-8

14*9

14-0

41-5

42-1

40-8

42-0

13-8

13-2

14-2

13-4

40-7

41-3

40*1

41-2

13-3

127

13-6

12-8

40-0

40-6

39-4

40-5

12-8

12-1

12-9

12-3

39-3

39-9

387

39-8

12*3

11-5

12-3

11-7

38-6

39-1

38-0

39-1

11-8

11-0

11-8

11-2

37-9

38-4

37-4

38-4

11-3

10-5

11-2

10-6

37-1

37-7

36-8

37-6

10-7

10-0

107

10-1

36-4

36-9

36*2

36-9

10-2

9-5

10-1

9-6

35-7

36-2

357

36-2

9-7

9-0

9-6

9*1

35-0

35-4

351

35-5

9-2

8-5

9-1

8-7

34*3

34-7

34-5

34-7

8-6

8-0

8-6

8-2

33-7

33-9

34-0

8-2

7-6

8*1

7-6

33-0

33-2

33-3

7-7

7-1

7-7

7-2

32-4

32-5

32-7

32-6

7-3

6-7

7-3

6-8

31-7

32-1

31-9

7-0

6-4

6-9

6-6

31-0

31-4

81-1

6-0

6-6

6-2

30-3

30-8

30-4

6-4

5-7

6-3

5-8

29-6

30-2

29-7

6-1

5-3

6-0

5-5

29-0

28*8

29-5

29-0

5-8

5-0

5 2

28-3

28'1

28-9

28-3

5-5

4-7

5-5

4-9

27-6

27*4

28*3

27-6

LITERATURE. — Marshall. On Marine Insurance. — Parke. On Insurance. — Charles
Crawley. The Law of Life Insurance, 1883. — H. T. Bewley. " On Albuminuria in Relation
to Life Insurance," Reports of the Insurance Institute of Ireland, 1892-93. — "W. R. Fox.
Insurance Institute of Victoria, 1887-89, p. 122. — James Begbie, M.D. Report on the Causes of
Death in the Scottish Widows' Fund Life Assurance Society, 1860 ; Idem. 1868. — Warburton
Begbie. Ibid. 1874. — Sir R. Christison. Report to Standard Life Assurance Co., 1850. —
Dr. A. P. Stewart. Characteristics of Assurable and Non-assurable Lives. — John Stott. ' ' On
the Mortality amongst Publicans," The Experience of the Scottish Amicable Life Assurance Society,
1826-76. — W. Robertson, M.D. The Causes of Death among the Assured in the Scottish Equit-
able Life Assurance Society, 1831-64. — M. A. Black. Assurance of Doubtful or Diseased Lives,
1861. — Grainger Stewart. On Albuminuria. — Bunyon and Fitzgerald. The Law of Life
Assurance, 3rd ed. — Low. " Extra Rating as a Statistical Problem," Brit. Med. Journal, vol.
ii. 1898, p. 772. — Cameron. " On the Duration of Human Life under various Conditions,"
Report of the Insurance Institute of Ireland, 1892-93, p. 135. — Discussions and Papers in the
Department of Medicine in Relation to Life Assurance at the British Medical Association
Meeting at Edinburgh, 1898, British Medical Journal, 1898, vol. ii. — Walford. The Insur-
ance Cyclopaedia. — Pollock and Chisholm. Medical Handbook of Life Assurance.

LIVER, PHYSIOLOGY OF

Lightening'. ^Medical Jurisprudence.

Liver. — This is described in the following sections : —

1. Physiology of.

2. Diseases other than those of "Tropical" origin.

3. "Tropical" Disorders, including Surgical Treatment (in vol. vii.).

467

Physiology of Liver

Outline op Structure

. 467

Functions —

General .

. 468

Carbohydrates

. 468

Fats

. 469

Proteids .... 469

Bile-formation . . .471
Influence op Nerves on the
Liver 473

Outline of Structure. — The liver originates as a branching tubular
outgrowth from the gut, and it must thus be regarded as primarily a
digestive gland.

At first the tubules run in an irregular manner, but with the growth of
the fibrous tissue they become massed into separate groups or lobules, with
their closed extremities pointing inwards and their orifices opening into a
network of ducts at the periphery of the lobule.

The original tubular character becomes lost, and the lumen of the tubules
is represented by narrow spaces between the cells, the so-called bile capil-
laries. The liver-cells thus seem to lie in rows radiating outwards from the
centre to the periphery of the lobule. Each cell is polygonal in shape, with
one or sometimes two large, round, centrally -placed nuclei, and a protoplasm
containing certain materials, varying in amount according to the condition
of the animal. When engorged with these matters the cells are much en-
larged and squeezed together ; when free of these substances, as in starvation,
they become smaller and more sharply defined.

One of the most obvious of these substances is Fat, in its characteristic
globules. In many animals on a fatty diet this is very obvious.

Glycogen occurs dissolved in the cytoplasm, and it may be demonstrated
by staining with iodine. It is very frequently confined to one side of the
cells. When the organ is treated with alcohol the glycogen is precipitated
in granules.

Pigment of a brownish colour, usually in granules, is also to be seen in
the liver-cells, especially when destruction of red blood corpuscles is going
on, and the presence of iron may be demonstrated by treating sections with
hydrochloric acid and then with ferrocyanide of potassium.

According to Langley, what he calls " proteid granules " are to be seen
in the liver-cells of the frog, especially in summer.

Minute channels passing into the protoplasm and communicating with
the bile capillaries have been described, but the true bile passages, which
commence as chinks between the liver-cells, form an anastomosing plexus of
ducts between the lobules. These are lined by a cubical epithelium. They
join together to form the larger bile ducts, and these present a columnar
epithelial lining and a fibrous coat with non- striped muscular fibres in its
substance. In many animals there is a diverticulum on the common bile
duct, the gall-bladder, which has the same structure as the bile passages, but
which, in some animals, has a few mucous glands opening into it.

The blood -supply of the liver is twofold. The hepatic artery supplies
the connective tissue of the organ, and the portal vein supplies the paren-

468 LIVEE, PHYSIOLOGY OF

chyma, but between them is a very free anastomosis. Both vessels are
carried in the fibrous tissue of the organ, and when such a piece of fibrous
tissue is cut across, the large branch of the portal vein and the smaller
branches of the hepatic artery, with one or two branches of the bile-ducts,
are to be seen forming a portal tract. These two sets of vessels terminate
in plexuses of capillaries between the lobules, and from these capillaries pass
inwards between the rows of liver-cells, and end in a central vein which
carries the blood from the lobules, and these central veins joining together
form the sublobular veins, which by their junction make the hepatic vein, by
which the blood is carried off to the inferior vena cava.

The nerves of the liver are non-medullated, and are derived from the
coeliac plexus, partly from the vagi, partly from the splanchnic nerves.

Physiology. — 1. General. — While the liver originates as an outgrowth
from the gut, it soon acquires other relations, and although it never
becomes so completely separated from the alimentary canal as do the
thyroid and thymus glands, its main functions are connected with the
general metabolism rather than with the digestion.

Early in intra-uterine life the ductus venosus bringing blood from the
developing placenta opens up into a capillary net-work among the liver
tubules, and the organ becomes permeated with sinuses through which the
blood slowly streams, and in which the nucleated red corpuscles divide and
multiply. About this time glycogen and fat, which have already appeared
in the placenta, begin to be found in the liver-cells.

As the alimentary canal develops, blood is sent from it to the liver, and
when at birth the placental circulation is stopped, and the animal is
nourished from the intestine, the liver remains upon the main channel of
absorption.

Both in intra- and in extra-uterine life the liver is the great regulator of
the supply to the tissues of the proteids, fats, and carbohydrates from which
the body gets its energy, and its action in this direction may be briefly
summarised as follows : —

(1) It regulates the supply of sugar —

(a) By manufacturing it from proteids when the supply of carbo-
hydrates is cut off.

(&) By storing it as glycogen when the carbohydrates are supplied in
greater quantities than are required by the body, and afterwards
giving it out as it is required.

(2) It regulates the supply of fat in many animals by storing any
excess.

(3) It regulates the supply of proteid, acting along with the intestinal
wall, by decomposing any excess and giving off the nitrogenous part as urea.

(4) It regulates the number of red corpuscles by breaking down the
older corpuscles and decomposing and eliminating the haemoglobin.

2. Regulation of Supply of Sugar to the Body. — That sugar is used
in the tissues, and chiefly in muscle, as a source of energy is demon-
strated by the large proportion of carbohydrates in the ordinary diet
of man, and by the excretion of its great product of combustion — carbon
dioxide — when sugar is taken. But although it is thus used in the tissues,
its amount in the blood is not diminished when the supply from with-
out is cut off. It must therefore be continually produced in the body,
and the fact that, when proteids are given in the food, glycogen is formed
from them in the liver, seems to indicate that in starvation this production
of sugar from proteids is carried on in that structure. This production
of sugar in the liver Bernard named its glycogenic functions. On account

LIVER, PHYSIOLOGY OF 469

of the small amount of sugar present in the blood, and of the imperfections
in the analytic methods at our disposal, the direct experimental evidence
upon this point is by no means satisfactory. But the indirect evidence
is sufficiently convincing, and in certain pathological conditions such as
diabetes the production of sugar from proteids becomes very manifest.

When the supply of carbohydrates in the food is excessive, the liver
takes up the surplus sugar, and by synthesis and dehydration, probably
effected only after the sugar has become part of the liver protoplasm, con-
verts it into the polysaccharid glycogen, and in this form stores it for future
use. There is evidence that this glycogen is in close chemical union with
the living matter, and that the separation is only brought about at the
death of the cell, or when it is being discharged. The various mono-
saccharids, e.g. glucose, levulose, galactose, can all be stored as glycogen, but
the disaccharid lactose, which is largely absorbed unchanged, is apparently
not available for glycogen production. Not only is glycogen thus stored
from the excess of carbohydrates taken in the food, but when large amounts
of proteid are given, these are to a great extent split up and the non-
nitrogenous part used in the formation of glycogen or of sugar. There is
no evidence that fats are a source of sugar or glycogen in the liver, though
recently attempts have been made to prove that they undergo such a
change in phloridzin poisoning.

The manner in which glycogen is reconverted to sugar must be con-
sidered as unsettled. Bernard and others have described the process as due
to a zymin in the liver, but other physiologists have been unable to accept
this view, and believe that it is a process similar to the conversion of
zymogen to zymin, and probably presided over by the nerves to the liver.
In support of the former view, the fact that an amylolytic zymin can be
extracted from the liver after death has been dwelt upon, while the latter
view is supported by the fact that many agents which do not influence
the action of zymins, e.g. quinine and methyl- violet, inhibit the conversion
of glycogen, and that this conversion is accelerated by stimulation of the
ccefiac plexus.

3. Regulation of Supply of Fat to the Body. — Although the liver
is not upon the channel of the absorption of fat from the intestine, in
many animals it has a very special power of storing any excess of
fats in the food. This function is perhaps best seen in the cod, and
it is well marked in the cat and in the human subject. On the other
hand, in the salmon, and in the pig and ox, the power of storing fat in the
liver is very limited. The fat thus stored is given out when the supply
from without is withdrawn. While the ordinary fats vary with the supply,
lecithin is a constant constituent of the liver-cells, even in prolonged starva-
tion. It has been suggested that this lecithin is the first step in the
synthesis of inorganic phosphorus to the complex nucleins of the cells, and
that the fats of the liver may act by combining with this phosphorus to fix
it and prevent its excretion.

4. Regulation of Supply of Proteids. — The researches of Nencki, Sieber,

and others have shown that any excess of proteid in the food is, in part at

least, broken down in the wall of the intestine, and that the nitrogenous

part is sent to the liver as ammonia compounds. Von Schroeder has

shown that such ammonia compounds, by a process of synthesis, are built

into urea —

H\ II ^/H

>N— C— N<

470 LIVEK, PHYSIOLOGY OF

During starvation the proteids of the body are broken down, the non-
nitrogenous part is converted to carbohydrates, and the nitrogenous moiety
is excreted as urea. Where this breaking down occurs is not known,
whether in the muscles or in the liver, but the ultimate stage of the manu-
facture of urea takes place chiefly in the liver. This is shown by the fact
that even partial destruction of the liver leads to an increase of the
ammonia in the urine and a decrease of the urea. By what stages the
formation of urea is brought about is not clearly known, but we do know
that proteids readily break down into amido-acids and ammonia compounds,
and that such compounds are changed into urea in the body.

But urea is not the only form in which the effete nitrogen of proteids
is eliminated. In foetal animals allantoin takes its place, while in birds
and reptiles uric acid, with traces of hypoxanthin and xanthin, are the
chief waste products. These substances are diureides — that is, they consist
of two more or less modified urea molecules linked by an organic acid.
Allantoin has as its linking bond glycoxylic acid, while the others have
acrylic acid. Uric acid is one of a series of bodies formed by modifying the
nucleus which Fischer has termed the Purin Nucleus —

Urea.

Acrylic Urea.
Acid.

C N—

7N"

c c =

C N—

Oxy-purin is Hypoxanthin.
Dioxy-purin is Xanthin.
Trioxy-purin is Uric Acid.

By the introduction of amidogen, Aminopurin or Adenin is formed, and
from this, Amino-oxypurin or Guanin is produced.

This series of diureides is formed when nucleins break down ; xanthin,
hypoxanthin, adenin, and guanin have thus been prepared, and although
outside the body uric acid has not been so produced, the administration of
nucleins leads to its increased formation within the body. In dogs allantoin
is formed when nucleins or uric acid are given. There is no indication that
the formation of uric acid in this way goes on in the liver, and, in fact, the
observation that it may be produced by digesting leucocytes with blood in
a stream of oxygen would tend to show that it goes on in other tissue.
The uric acid and other purin bases so formed are all, in part at least,
further changed to urea in the liver.

But there is another mode of formation of uric acid, which occurs in
birds and reptiles, and, at least under certain conditions, in man. In the
former type of animals the ammonium lactate —

H OH 0

i i II
H— C— C— C— NH4
i i
H H

which in mammals is changed to urea, is converted to uric acid. Now
when it is remembered that sarcolactic acid is hydroxy-propionic acid, and
that acrylic acid, the linking bond in uric acid, is an unsaturated propionic
acid, it is obvious that uric acid may be formed either directly on the road
to the formation of urea or only very slightly off that road.

LIVEB, PHYSIOLOGY OF 471

That uric acid in birds is formed in the liver is shown by Minkowski's ob-
servation that when the liver is removed lactate of ammonia takes its place
in the urine. This production of uric acid must be carried out by a process of
synthesis, since the amount of nitrogen is greater in uric acid than in lactate
of ammonia, and that this synthesis is carried out as part of the metabolism
of the liver protoplasm is indicated by the fact that in birds urea is changed
to uric acid, and that in dogs uric acid is changed to urea and to allantoin.

Now in certain conditions of the liver in mammals the process of the
elaboration of urea either stops to a greater or less extent at the stage of
uric acid or by a slight modification is in part diverted to it, and thus the
proportion of uric acid to urea rises. What these conditions are has not
been fully investigated, but apparently maloxygenation of the blood and
the action of various toxic substances in the liver are apt to induce this
alteration in the metabolism.

One proteid, with the breaking down of which the liver has a very direct
relation, is haemoglobin. This may be considered as a compound of about
96 per cent of a globulin, with 4 per cent of an iron-containing pigment,
hsematin. The liver-cells take up haemoglobin, break it into its two com-
ponents, and split the hsematin into an iron -containing part which is
retained for further use, and an iron-free portion which is excreted as the
pigment of the bile. It also breaks down the globulin and forms urea,
and thus when experimentally a large amount of haemoglobin is set free
in the circulation, the excretion of urea is proportionately raised.

The relationship of the liver to proteids and haemoglobin leads to the
study of its

5. Bile-forming function. — Formerly the formation of bile was considered
the function of the liver, and it was only after Claud Bernard had discovered
its glycogenic function that the secondary nature of bile production was
recognised.

Bile is an alkaline, viscous, olive-yellow fluid. "When secreted from the
liver-cells it has a specific gravity of about 1010, and contains about 2 per
cent of solids. When it has been some time in the gall-bladder, water is
absorbed, and it becomes more viscous and the percentage of solids rises.

In freshly secreted bile the inorganic salts amount to less than 1 per
cent. The principal salt is chloride of sodium. The chief constituent of
the bile is the soda salt of glycocholic acid. A small amount of taurocholic
acid is also present in human bile. These salts are alkaline in reaction.
Glycocholic acid readily splits into cholalic acid, C24H40O5, the constitution
of which is not definitely known, and amido-acetic acid (glycocoll) —

H 0

i II
NH2— C— C— OH
I
H

Taurocholic acid yields cholalic acid and amido-ethane-sulphuric acid
(taurin) —

H H O

i > ii

NH2— C— C— S— OH

I I II

H H 0

Since these both contain amidogen they must be derived from proteids.
That these acids are formed in the liver and not merely excreted by it is
shown by the fact that whereas when the bile-ducts are ligatured they

472 LIVEK, PHYSIOLOGY OF

appear in the blood, when the liver is excluded from the circulation they do
not appear. They may be considered as the essential constituents of the
bile, and it is their presence which gives to bile any action it may have in
digestion. About 7 or 8 grams are excreted per diem.

The pigments bilirubin, biliverdin, and biliprasin are derived from the
decomposition of the hsematin of haemoglobin, and they are increased when
haemoglobin is set free. The fact that they do not appear in the blood
when the Liver is excluded from the circulation shows that they are formed
in the organ and not merely excreted by it. They amount to about half a
gram per diem.

Cholesterin, C26H43OH, is a monatomic alcohol insoluble in water, but
dissolved in the salts of the bile acids. The amount secreted in normal
conditions is small. That it is not merely excreted by the liver is shown
by the fact that when injected or given in the food it does not appear in
the bile. It is probably formed from the cells of the bile passages, since re-
searches carried on in Naunyn's laboratory show that when these passages are
inflamed the cholesterin is increased. It is the chief constituent of gall-stone.

Fats and Lecithin are present in small amounts, and are derived from
the liver-cells.

The viscosity of bile is due to the presence of a nucleo-proteid, with
small traces of mucin. These are formed in the bile-passages.

The action of bile in digestion is unimportant, since its exclusion from the
intestine does not prejudicially affect either men or animals. Its only action
is as an adjuvant to the pancreatic juice by dissolving the fatty acids set free,
and thus favouring their absorption. When the bile does not enter the in-
testine, about 30 per cent of the fats escape absorption, and it is the presence
of these which gives the peculiar white appearance to the stools in jaundice.

The very small importance of bile in digestion raises the question of
how far it is to be regarded as a digestive secretion and how far as a waste
product. The facts that its secretion begins before birth and is continuous
during starvation, that its formation has no immediate relationship with
the taking of food, that its pigment is derived from the decomposition of
haematin and its chief constituents — its acids — from proteid disintegration,
all strongly support the view that it is a waste product which has come to
play a minor part in digestion. There is no evidence that the proteids of
the food are excreted as the acids of the bile, and it must be concluded that
they are derived from the proteids of the body generally, or more probably
from the waste of the liver tissue itself.

Excretion of Toxic Substances by the Liver. — The study of bile secretion
leads to the consideration of another function which the liver seems to
perform. It has been found that it can take up pigments of various kinds
and secrete them in the bile. It has also been shown that the salts of
the bile acids are reabsorbed from the intestine, carried to the liver, and
again secreted. Now, certain other substances are treated in the same way.
Curare, when administered hypodermically, is a powerful toxic agent, but
when taken by the mouth its action is not manifested. It appears to be
absorbed, carried to the liver, and excreted in the bile. It seems to circulate
in the portal circulation until gradually eliminated from the bowel, and
thus is prevented from entering the general circulation. At one time it
was supposed that snake venom, which is not toxic when swallowed, under-
goes the same treatment, but Fraser has shown that bile has a destructive
action upon it. Possibly ptomaines formed in the intestine are prevented
from producing their prejudicial effect by being re-excreted by the liver and
in this manner got rid of.

LIVEE, DISEASES OF

473

Influence of Nerves on the Livek. — The influence of the nervous
system has been investigated on only two of the functions of the liver, the
secretion of bile and the production of sugar.

The subject is much complicated by the fact that the nerves act upon
the blood-vessels, and that both bile-production and sugar-production are
influenced by the vascularity of the organ. Thus it has been shown that
section of the splanchnic nerves, which causes dilatation of the blood-vessels,
causes an increased flow of bile, while stimulation of these nerves causes a
diminution in the secretion. Similarly, factors which dilate the vessels tend
to cause a more rapid conversion of glycogen to glucose.

Apart from this indirect influence, there is so far no evidence that the
secretion of bile is governed by the nervous system, while the facts that
injection of pilocarpine, which increases the flow of saliva and of pancreatic
juice, has no effect on bile secretion, and that atropine does not arrest it,
seem opposed to the idea that there is any nervous mechanism directly
involved. On the other hand, the flow of bile already secreted into the bile-
passages is directly under the control of the nerves, and a discharge of bile
into the duodenum is reflexly brought about when food is taken.

Eecently a good deal of evidence has been forthcoming of a direct
influence of the nervous system on the glycogenic function of the liver.
Cavazzani has shown that stimulation of the coeliac plexus causes glycogen
to be converted into sugar, and Butler states that stimulation of the peri-
pheral end of the cut vagus increases the amount of sugar in the blood
leaving the liver. This may of course have been due to vascular dilatation.

LITERATURE.— Schafer. Text-Book of Physiology, 1900 (with Literature).

Diseases of Liver

Anatomical Abnormalities

Liver .

Biliary Apparatus

Post-Mortem Changes

Acquired Deformities

Displaced Liver .
Hepatoptosis .
Functional Disease .
Diseases of —

Hepatic Artery .

Hepatic Veins

Lymphatic Vessels
Chronic Venous Engorgement .

Hepatic Pseudo-Cirrhosis .

Hepatic Infarcts
Biliary Cirrhosis —

(a) Hypertrophic Biliary
Cirrhosis

(6) Obstructive Biliary

Cirrhosis
Portal Cirrhosis
Varieties of Hepatic Cirrhosis in

Early Life
Degenerations and Infiltrations

Fatty Liver

Lardaceous Liver

474

474
474
475

475
477
479
483

486

488
489
489
493
494

495

502
503

520
521

521
524

Pigmentary Change
Calcareous Infiltration
Leukemic Infiltration
Tumours of Liver
Innocent Tumours
Adenoma .
Angioma .
Lipoma
Cysts of Liver .
Infective Granulomata
Tubercle
Syphilis
Lymphadenoma
Actinomycosis
Malignant Disease
Primary
Carcinoma .
Sarcoma
Secondary .
Special Conditions characterised
by Jaundice —
Icterus Gravis
Acute Yellow Atrophy
Weil's Disease
Jaundice of Phosphorus Poison-
ing, vol. v. p. 533.

525
525
526
527
527
527
530
531
531
533
533
537
546
546
547
547
548
549
552

554
555
561

474

LIVEB, DISEASES OF

Anatomical Abnormalities

Liver

Biliary Apparatus
Some Post-Mortem Changes
Acquired Deformities

474
474
474
475
475

Tight-laced Liver, or Corset

Liver .... 475

Tongue-shaped Lobe . . 476

Displaced Liver — Congenital . 477

Acquired . 477

In general transposition of the viscera the liver is on the left side of the
body, and the left lobe is the larger. Cases sometimes occur in which the
liver is in its normal situation, but the left lobe is large and the right lobe
small — transposition of the lobes without situs transversus. Sometimes
one lobe — often the left — is found to be dwarfed out of all recognition,
and to be represented only by a small appendage attached to the other ;
this is probably a result of some interference with the blood-supply early
in life. When the left lobe is practically absent the stomach is more
widely uncovered, and the gall-bladder . appears to arise from the left
border instead of from the under surface of the liver.

Small accessory lobes, of about the size of the last joint of the fore-
finger, are fairly common; they are more frequently seen on the under
surface of the right lobe of the liver. If they become markedly pedun-
culated they might form small " accessory livers." The Spigelian lobe has
been observed to be curiously pedunculated.

Very rarely small detached pieces of hepatic substance have been
found in the falciform or other peritoneal ligaments of the liver, " accessory
livers," or hepatic " rests." It is noteworthy how rare hepatic " rests " are,
as compared with accessory suprarenal bodies and splenunculi.

Extensive lobulation of the liver is a condition sometimes met with ;
there may be as many as 16 lobules; this lobulation is, I believe, not
homologous with the foetal lobulation of the kidney, but pathological, and
due to some pre-existing morbid process, such as syphilis, or possibly
tuberculosis, perihepatitis, or coarse cirrhosis.

Abnormalities in the Gall-Bladder and Bile Ducts. — Complete absence
of the gall-bladder — the normal condition in the horse and other animals —
is sometimes seen in men ; this must be distinguished from early patho-
logical obliteration of an existing gall-bladder, such as occurs in congenital
obliteration of the ducts.

On the other hand two gall-bladders, each with a cystic duct, have
been seen in the same liver (Purser); a bifid gall-bladder has also been
described.

An hour-glass contraction of the gall-bladder is generally associated
with gall-stones, and is probably a secondary change. In cases where the
fundus of the gall-bladder projects beyond the anterior margin of the liver,
the terminal portion, being somewhat dilated, may appear to be separated
from the rest by an hour-glass constriction. Personally, I regard the
hour-glass gall-bladder as an acquired and not a congenital change.

Direct communications between the gall-bladder and the liver (hepatico-
cystic ducts) are sometimes found to occur in men. The gall-bladder has
been found attached to the left lobe instead of to the right. Considerable
variation may exist in the arrangement of the larger bile ducts. Some-
times the two hepatic ducts do not unite until comparatively close to the
duodenum. The common bile duct may open quite separately from Wir-
sung's duct into the duodenum.

LIVER, DISEASES OF 475

Post-mortem Appearances of the Liver. — A few words may be said about
certain common though striking post-mortem appearances of the liver.

The surface of the liver, where it has been in contact with the stomach
or colon, very commonly shows dark purple stains. These stains are quite
superficial and are due to the action of gases, among them sulphuretted
hydrogen, which diffuse through from the colon and stomach, and meet
with iron in the liver ; as a result, some compound like sulphide of iron is
manufactured.

Irregular white areas on the surface of the liver are seen in cases of
fevers and other infections, and show congestion and degeneration changes
(Hanot). This appearance was formerly thought to be merely due to
mechanical pressure exerted after death in laying out the body.

Cloudy Swelling. — After death, one, if not the most frequent, change in
the liver is that of cloudy swelling. The organ is enlarged, heavier than
natural, and looks as if it had been boiled, being dull, somewhat more
opaque, and paler in colour than normal. These changes are due to cloudy
swelling or parenchymatous inflammation of the liver-cells set up by the
toxines of numerous diseases. The changes which are shared by other
organs, such as the kidneys and myocardium, are especially well seen in
pneumonia. In this disease the enlargement of the liver is very consider-
able. Long ago Bright thought that the pneumonic lung materially
depressed the liver, but it is clear that any increased hepatic dulness
below the costal arch is due to cloudy swelling and congestion.

Foaming Liver. — Under certain conditions the liver becomes infected,
shortly before or at the time of death, with the bacillus capsulatus
aerogenes, with the result that it becomes a spongy mass of gaseous cysts.

ACQUIRED DEFORMITIES OF THE LlVER

Effect of Tight-Lacing on the Liver. — Modifications in the shape of the
liver due to tight-lacing and corsets are, of course, commoner in women,
but considerable deformity of the liver may be produced in men by the
pressure of a tight belt or strap.

The effect of tight-lacing on the liver varies to a certain extent with
fashion, or, in other words, with the position of the waist. Hirtz, who has
studied the changes produced in the liver by tight-lacing in great detail,
finds that the deformities of the liver may be divided into two main types,
though mixed or transitional forms may occur.

(1) The liver is flattened from above downwards, the right lobe is
elongated, and at the point where it passes over the right kidney is
thinned, so that below this point there is a constriction or movable lobe
attached by a fibrous hinge, so to speak, to the rest of the liver. To this
condition the term partial hepatoptosis has been applied. Sometimes the
left lobe is similarly prolonged downwards, and may have a constriction lobe
attached to it. Frerichs figures a capital example. It has indeed been
thought that such a constriction lobe is more likely to give rise to
symptoms from the ease with which it would press on the stomach, pylorus,
pancreas, and large nerve plexuses. But it is doubtful whether this is so.
Clinically there is a close resemblance between these constriction lobes
of the right lobe and the tongue-shaped or Biedel's lobe usually described
as occurring in special association with gall-stones. From impaired nutri-
tion and diminished resistance morbid changes are more likely to occur in
the constriction lobes than in the remainder of the liver ; thus fibrosis or

476 LIVEE, DISEASES OF

gummata may be confined to them. On the other hand, the whole of the
liver, constriction lobe included, may be uniformly affected by cirrhosis.

(2) The liver lies high in the abdominal cavity, and is much thicker
above than below. It is curved across the spinal column so that the left
lobe may touch or even overlap the spleen. The fossa for the inferior vena
cava is exaggerated ; while the lower margin of the right lobe is compressed
by the belt or corset, and shows local perihepatitis and underlying atrophy.
The circumferential pressure may throw the upper surface of the liver
into folds. These furrows are often seen on the convexity of the right lobe,
and have been thought to be due to indentations of the ribs, or to be due to
the impress of folds, or hypertrophied columns, of the diaphragm, since they
are said to occur in cases where respiration has been difficult during life,
such as bronchitis and emphysema. A constriction lobe may be found
attached to the right lobe, but is not a constant feature as in the previous
form, and is never present in connection with the left lobe.

Clinical Significance. — Tight-laced livers may and often do coexist with
dyspepsia, which no doubt partly depends on the abdominal or gastric em-
barrassment produced by the pressure of a tight corset. Very frequently,
however, the patient has no symptoms in any way referable to a tight-laced
or corset liver. The chief interest about a tight-laced liver is that the
constriction lobe may, when accidentally detected, be easily mistaken for
something more important, such as a floating kidney, a tumour of the pylorus
or transverse colon, a dilated gall-bladder, cysts of the pancreas or of the
mesentery, or, in extreme cases, a fibromyoma of the uterus, an ovarian
tumour, or appendicitis. The connection between the constriction lobe and
the main part of the liver, as has already been pointed out, is sometimes
very thin, and may therefore give a resonant note on percussion. Its actual
continuity with the remainder of the organ is therefore difficult to make
out.

Tongue-like Lobes

Synonyms : Linguiform lobe, BiedeVs lobe, Partial hejpatoptosis, Floating
lobe. — This condition is very much the same as the constriction lobes that
have been described in the corset liver. The association of these tongue-
like lobes with distension of, or with the presence of calculi in, the gall-
bladder appeared extremely intimate to Eiedel, after whom these lobes
have sometimes been called, and was therefore regarded by him as
corroborative evidence of gall-bladder disease in any case of doubt. It has
indeed been thought that these tongue-like lobes are only produced by
gall-bladder distension, inflammation, or calculi, but this is probably too
exclusive a statement. Tight-lacing must also be taken into account, especially
as it may lead to bending and twisting of the cystic duct, and so to partial
obstruction of the outflow of bile from the gall-bladder, thus disposing
to catarrh and so to cholelithiasis.

The elongation of the right lobe downwards carries with it the gall-
bladder, and since this is often affected with calculous cholecystitis, the
abnormal lobe is frequently the site of pain.

As in the case of the constriction lobes of the corset liver, this abnormal
lobe may be connected with the liver only by a thin bridge of fibrosed
hepatic substance, and may easily be regarded as some form of abdominal
tumour, such as a floating kidney, a tumour of the pylorus or colon, and
the other tumours mentioned in the section on tight-laced liver.

From repeated attacks of congestion the floating lobe is very often
structurally altered and shows fibrous increase.

LIVER, DISEASES OF 477

The subjects of floating lobes are usually women of mature years, and,
as has been already said, gall-stones are frequently found in association.
M'Phedran, however, has described a case in a baby aged 11 months, and
is inclined to regard these lobes as of developmental origin.

The floating lobe is freely movable, and may be tender on palpation.
The symptoms referred to it are a feeling of heaviness and dragging in the
hypochondrium, pain sometimes like biliary colic, and in all probability due
to gall-stones. It should, however, be pointed out that it may be associated
with a floating kidney.

The tongue-shaped lobe is rarely diagnosed clinically, and is usually
only discovered when an exploratory laparotomy is undertaken. The
condition has been known to disappear after associated disease of the gall-
bladder has been removed, and this is the rational and most satisfactory
treatment.

In some recorded cases the floating lobe has been successfully fixed by
sutures to the abdominal wall, or even removed with relief of the symptoms
referred to its presence. But such radical measures are not really
necessary, since it is doubtful whether serious symptoms are ever due to
the floating lobe apart from associated disease of the gall-bladder.

LITERATURE. — Tight-Laced Liver : Frerichs. Diseases of the Liver, vol. i. p. 44,
New Sydenham Society. — Hertz. Abnormitaten in der Lage und Form der Bauchorgane,
1894. Tongue-like Lobe: M'Phedran. Canadian Practitioner, June 1896. — Riedel.
Berlin, klin. Woclien. 1888, Nos. 29, 30.— -Treves. Lancet, 1900, vol. i. p. 1342.

Displaced Liver

This condition must be distinguished from a movable or displaceable
liver, which is considered in the next section on hepatoptosis, and from the
various enlargements of the liver.

Displacement of the liver may be due to causes that are —

(1) Congenital.

(2) Acquired.

Congenital Malposition or Displacement of the Liver is rare. — When the
diaphragm is defective or represented only by a membranous partition, the
liver may project upwards into the thoracic region inside a thin pouch. In
twelve cases of true congenital diaphragmatic pouches collected by Jaffe,
eight were on the left side. The left lobe of the liver has been found in
these pouches, and its displacement naturally gives rise to tilting of the
organ.

From congenital defect of the abdominal muscles the liver may project
under the skin either at the umbilicus or between that point and the
xiphoid cartilage. When it occurs at the navel it is spoken of as hepat-
omphalos, when elsewhere as congenital ectopia, or hepatocele. The tumour is
dull on percussion, and can be reduced unless it contracts adhesions to the
wall of the hernial sac.

Acquired displacements of the liver may be due to very various
causes.

In angular curvature of the spine, the liver, like other organs, may be
very considerably displaced. In rickets the deformity of the thorax may
account for some of the increased extent of the hepatic dulness below the
costal arch. The liver is generally regarded as being enlarged in rickets.
This is partly real, partly apparent as explained above. In tight-lacing
narrowing of the lower part of the thorax often squeezes the liver down-
wards.

478 LIVEE, DISEASES OE

In traumatic diaphragmatic hernia the liver may pass through the rent
into the cavity of the pleura ; a constriction has in some cases been found
between the intrapleural portion and the rest of the liver; under these
conditions the distal portion may become very congested. Acquired
diaphragmatic hernia is very much commoner on the left side; it may
contain the left lobe of the liver.

Among the intra-thoracic conditions that give rise to displacement of
the liver the most important are pleural effusion and pneumothorax on the
right side. The right lobe is depressed and the liver then tends to be
rotated from right to left on its antero-posterior axis. Similar conditions
on the left side or a large pericardial effusion will depress the left lobe of
the liver. Emphysema and very extensive infiltration of the lung with new
growth also push the liver downwards, but only to a comparatively slight
degree. In mediastinal tumour there is no displacement of the liver,
unless, as not infrequently occurs, there is a large pleural effusion at the
same time.

Abdominal Conditions leading to Displacement of the Liver. — Generally
speaking, abdominal conditions that displace the liver do so in an upward
direction, but occasionally the liver may be depressed or rotated from side
to side. Ascites, flatulent distension of the intestines, congenital dilatation of
the colon, or the presence of large abdominal tumours, such as ovarian cysts,
uterine fibro-myomata, etc., push the liver and diaphragm up, and thereby
encroach very seriously on the capacity of the thorax. The convexity of
the diaphragm may then be on a level with the third rib. When this
upward displacement is very considerable the liver may largely or even
entirely cease to be in contact with the anterior abdominal wall, and
undergoes a very striking alteration in its relation to other organs. The
anterior surface travels backwards and becomes posterior, while the inferior
surface comes to look forwards and upwards instead of downwards and
backwards. This is due to the liver moving upwards on a transverse axis
running through its connection with the inferior vena cava which is relatively
a fixed point.

Occasionally coils of intestine or the colon may intervene between the
liver and the anterior abdominal wall, thus displacing the liver backwards.
In acute yellow atrophy complete disappearance of the liver dulness is
largely due to the flabby liver allowing resonant bowel to come between it
and the abdominal parietes.

A subdiaphragmatic abscess, especially one between the liver and the
diaphragm, such as results from rupture of a suppurating focus on the
convexity of the liver (suprahepatic abscess), or a hydatid cyst lying
between the liver and the diaphragm, may depress the liver.

As the result of inflammatory adhesions the liver may be pulled down-
wards towards the pelvis. In very rare instances a wandering liver has
become fixed by peritoneal adhesions in an abnormal position such as the
right iliac fossa (Richelot).

Dilatation and distension of the stomach or of the left part of the colon
will rotate the liver on its antero-posterior axis towards the right.

A displaced liver is, as a rule, not more movable than one in its normal
position. It differs from a wandering liver in this respect, and also in the
fact that it cannot be replaced in its normal position, while in addition a
definite cause for its displacement is often forthcoming.

Symptoms that might be referred to a displaced liver, such as weight
and pain in the right hypochondrium, are generally thrown into the shade
by those of the condition responsible for the displacement.

LIVER, DISEASES OF 479

The various forms of enlargement of the liver, fatty, lardaceous,
leukemic, new growth, abscess, cirrhosis, etc., must be differentiated from a
displaced liver by a careful physical examination of each individual case.

LITERATURE. — Frerichs. Diseases of Liver, vol. i. p. 45, New Sydenham Society. —
Graham. Canadian Practitioner, June 1895. — Jaffe. Trans. Path. Soc. vol. xlv. p. 224. —
Richelot. Gaz. des h6p., 1893, p. 783. — Treves. Article " Enteroptosis," Allbutt's System,
vol. iii.

Hepatoptosis

Symptoms . . . .481

Diagnosis . . . .482

Treatment . . . .482

Definition, etc. . . . .479
Etiology 479

Causation . . . . .479
Physical signs . . . .481

Synonyms. — Wandering liver; Movable liver; Ptosis, Dislocation,
Prolapse of the liver.

Definition. — The liver being unduly movable in a downward direction
leaves its normal position and appears as an abdominal tumour.

Historical. — Heister as long ago as 1754 published an account of an
autopsy, illustrated by a plate, showing this condition, but Cantani is credited
with the first clinical recognition of wandering liver in 1865. Attention
has been largely directed to this curious anomaly by the numerous con-
tributions of Glenard, who has recently collected 80 examples.

Introductory. — A movable liver must be distinguished from mere dis-
placement of the organ by pleural effusion, etc., and from the constriction
or floating lobes that have been termed partial hepatoptosis. It is probable
that what were really only floating lobes have often been described as
wandering livers or complete hepatoptosis.

A wandering liver is analogous to a wandering spleen ; both the organs
are normally "floating," viz. supported by the abdominal viscera and tethered
by peritoneal ligaments. The term "floating" is therefore unsuitable as
descriptive of an abnormally movable liver, though it is applicable to
nephroptosis. When these normally " floating " organs become unduly and
spontaneously movable they may be said to be " wandering."

Etiology. — The female sex are chiefly affected ; out of 80 cases collected
by Glenard 73 were in females, Graham in 70 cases found 56 in women,
while in 30 cases seen in private practice Max Einhorn records 21 in
women. The majority of patients are over 40 years of age ; cases in early life
are very rare, Freeman in 494 autopsies on children records 4 instances of
hepatoptosis.

Repeated pregnancies, abdominal distension, and other causes leading
to a relaxed and pendulous condition of the abdominal parietes, dispose to
hepatoptosis. Tight-lacing may by interfering with the healthy tone of the
abdominal muscles indirectly dispose to hepatoptosis, but it plays a minor
part, and its chief manifestations have been already referred to (p. 475).

Causation. — An unduly movable liver may be part of general abdominal
ptosis or Glenard's disease, already described. (See "Enteroptosis.")
On the other hand, hepatoptosis may exist without universal visceroptosis,
or only in association with one of its manifestations, such as floating
kidneys.

A considerable amount of discussion has taken place as to the essential
factors in the production of a movable liver. Erom a general survey it
appears that the necessary conditions are —

(1) Diminution in the Intra-abdominal Tension. — This allows the sup-

480 LIVEE, DISEASES OF

porting pad of intestines to fall away from the liver, and permits that organ
to drop down towards the pelvis. The causes which lead to lowering of the
intra-abdominal pressure are numerous ; among them may be enumerated
repeated pregnancies, ascites, abdominal distension, sedentary occupations,
tight-lacing, and an enfeebled state of health ; all of these tend to impair
the healthy tone of the muscles of the abdominal wall, and to produce a
pendulous state of the abdomen. Though undoubtedly a very important
factor, diminution of the intra-abdominal pressure is probably not of itself
sufficient to induce complete hepatoptosis.

(2) Failure in the Suspensory Apparatus of the Liver. — This is probably
somewhat subordinate in importance to diminished intra-abdominal pressure,
but is a necessary condition to the production of hepatoptosis.

The liver is suspended in its place by the following means : — (a) By
the suspensory and coronary ligaments. It has been thought that they
may be congenitally absent or deficient ; this may be so in a few isolated
instances, but it is so exceptional an occurrence that it cannot be maintained
that congenital abnormalities in these peritoneal folds have any real bearing
on the production of movable liver. It is much more probable that relaxa-
tion of these ligaments is acquired and due to nutritional defects, such as
may well be responsible for atony of the abdominal parietes. It has been
suggested that fatty and generative changes are induced in the ligaments.
(b) By the Inferior Vena Cava. — Faure has laid great stress on the im-
portance of the inferior vena cava in keeping the liver in contact with the
diaphragm. Probably defective general nutrition will lead to relaxation of
its controlling influence in the same way as in the case of the suspensory
ligaments.

The immediate cause of hepatoptosis may be found in sudden injuries
or strains, the displacement then resembling a traumatic dislocation; in
other cases repeated efforts, such as coughing, vomiting, sneezing, or pro-
longed straining, have been invoked. In many cases no definite determin-
ing cause is forthcoming.

Foems of Hepatoptosis. — The liver is not simply displaced downwards ;
its shape is considerably modified, and it frequently becomes rotated on one
or more of its axes.

The liver settles down and becomes flattened out so as to lie like an
apron over the intestines ; the superior or diaphragmatic surface tends to
become anterior, and the inferior surface to become posterior. The organ
hangs down from its attachment to the inferior vena cava, and is so thinned
and elongated that it may reach the right iliac fossa. The liver is thus
anteverted or, in other words, rotated forwards on its transverse axis, and
its long axis becomes vertical instead of oblique.

Frequently the liver is in addition rotated on its antero-posterior axis.
From the fact that the most fixed point of the liver is its attachment to
the inferior vena cava, the right lobe, which is the heavier as well as the
more movable, descends more freely than the left lobe, which may be the
only part left in contact with the diaphragm. The position of the liver
thus becomes oblique, the right lobe being tilted downwards and depressed.

A further change may be met with, viz. rotation of the liver on its long
or vertical axis, so that the anterior surface looks towards the right and the
posterior surface to the left ; in rare instances the liver is said to be rotated
in the opposite direction, so that the anterior surfaces face towards the left
and the posterior towards the right.

There are thus at least three forms of movable liver.

The flattened and elongated liver frequently shows a line of constriction

LIVEll, DISEASES OF 481

running transversely across its anterior surface. This is probably due to
the pressure exerted by the costal margin and tight-lacing. The line of con-
striction may become so thin as to contain little but blood-vessels between
the two layers of somewhat thickened peritoneum. A constriction lobe is
then found attached to the rest of the liver by a kind of tendinous
hinge.

Generally speaking the liver itself is healthy, but in a certain number
of instances the existence of concomitant disease, such as gall-stones or
cirrhosis, has been recorded.

Occasionally a movable liver contracts adhesions, and becomes fixed in
an abnormal part of the abdomen ; in consequence it cannot be replaced in
the normal position, and presents great difficulties in the way of a correct
diagnosis.

Physical Signs. — There is an abdominal tumour which is displaceable,
and can be returned to the normal position of the liver. It resembles the
liver in outline, size, and in descending on respiration, while examination
of the normal situation of the liver shows that the organ is partially or
entirely absent. The normal liver dulness is replaced by resonance, and
the right hypochondrium is sunken.

When the organ is very freely movable, it not only moves with change
of posture, descending when the patient sits up, and tumbling to the left
when he is turned on that side, but it can be rotated on its vertical axis,
an exaggeration of the displacement induced by a dilated stomach or colon
under ordinary conditions of hepatic stability. The relaxed condition of the
abdominal walls often renders the liver visible as a rounded tumour on the
right side, about the level of the umbilicus, extending down into the right
iliac fossa and approaching the pelvis. Other forms of visceroptosis, such
as a floating kidney, displaced stomach or uterus, etc., may be present.

Symptoms. — The onset is generally insidious and attracts no atten-
tion ; in a few instances it is suddenly manifested by pain, like that of
biliary colic, or a feeling of something giving way, and suggests traumatic
dislocation.

Cases of hepatoptosis sometimes present no symptoms, and the condition
is only discovered accidentally. On the other hand patients may complain
of one or more of the following symptom groups : —

1. Pain and a feeling of weight in the right hypochondrium are very
common ; the traction exerted by the liver may be transmitted through
the diaphragm, pericardium, and cervical fascia to the root of the neck and
be felt there. These symptoms are made worse by exertion and are relieved
by lying down.

2. Symptoms imitating Cholelithiasis. — Sometimes attacks of colic,
which may resemble biliary colic, are met with ; they may be explained as
due to torsion of the bile ducts, or possibly to concomitant cholelithiasis.
In other cases intestinal colic occurs, and is probably due to ptosis of the
colon. Jaundice rarely occurs in hepatoptosis; it may be the result of
torsion, gall-stones, or be of a simple catarrhal nature.

3. Symptoms imitating Cirrhosis. — Ascites and hsematemesis have been
met with, and have been referred to twisting of the portal vein ; in like
manner oedema of the feet has been explained by kinking of the inferior
vena cava. These symptoms are infrequent.

4. Symptoms referable to the*respiratory system are somewhat uncom-
mon. In some instances dyspnoea and asthmatic symptoms appear to
depend on hepatoptosis (Max Einhorn). Persistent cough has been found
to be associated with displaceable liver, and to be cured when appropriate

VOL. vi 31

482 LIVEE, DISEASES OF

treatment — the application of a bandage — for the latter condition was
adopted (Vene).

5. In a considerable proportion of the cases the symptoms are not due
to hepatoptosis alone, but to complete or partial visceroptosis. Thus the
neurasthenic or hysterical manifestations, so commonly associated with
visceroptosis, may be most prominent features. In other instances the
symptoms are referable to the stomach and intestines, such as dyspepsia,
vomiting, constipation, flatulence, mucous colitis, etc. Though congestion
of a displaceable liver may play a considerable part in the production of
these functional disturbances, they are intimately connected with viscero-
ptosis (vide Glenard's disease, article " Enteroptosis "). In other instances
the symptoms may be chiefly due to a floating kidney, while in others leu-
corrhcea, menorrhagia, etc., due to visceroptosis, are complained of.

Diagnosis. — The presence of a movable tumour resembling the liver,
taken into conjunction with evidence that the liver is absent from its normal
position, are the essentials in the diagnosis. But care must be taken in
distinguishing it from a floating lobe with or wi.thout a distended gall-
bladder, from simple downward displacement due to factors like pleural
effusion (see p. 478), and from enlargement of the liver depending on
malignant disease or other causes. One of the most frequent mistakes
seems to be to regard as a floating kidney what is in reality a prolapsed
liver ; the former condition is of course more familiar and may complicate
hepatoptosis. In a case of doubt an attempt should be made to replace
the movable tumour in the hepatic region, while careful note should be
made of the extent of the liver dulness and the relation of the intestines to
the tumour.

Hepatoptosis has been mistaken for various other abdominal tumours
and conditions, such as omental or renal tumours, carcinoma of the
stomach, hydatid cysts or malignant disease of the liver, gall-stones, and
even for ovarian cysts.

Treatment. — A suitable bandage, belt, or apparatus should be applied
to the abdomen so as to support the abdominal walls and keep the liver in
its proper place. Massage and electricity have been employed in order to
strengthen the abdominal muscles and improve their tone.

Diet is a matter of importance; generally speaking the subjects of
hepatoptosis are feeble, wanting in tone, and require good and liberal feeding
to improve their state of nutrition. When there is decided corpulence the
amount and quality of the food will require careful consideration by the
medical attendant.

Symptoms of neurasthenia and nervous debility should be treated on
appropriate lines. Constipation should be met by massage and purges, so
as to prevent congestion of the liver and accumulation of bile in the gall-
bladder.

When all other measures fail to relieve the symptoms, and the patient
is quite incapacitated, the advisability of surgical interference must be
considered. Various methods of fixing the liver permanently in its normal
position, or " hepatopexy," have been employed, such as suturing the pro-
lapsed liver to the costal arch or anterior abdominal wall, or fixing the round
ligament to the abdominal wall while at the same time promoting adhesions
between the convexity of the liver and the diaphragm. The operation has
in many cases been successful, but should only be undertaken when all
other means have failed. The objections to its adoption are (i.) that it
hardly affects the underlying conditions responsible for the prolapse of the
liver, though it may counteract them, and (ii.) that the wound made at

LIVEE, DISEASES OF 483

the time of the operation may subsequently become the site of a hernial
protrusion. This is more likely to occur in old women with pendulous
abdominal walls than in younger patients. In any case an abdominal belt
should be worn after the operation.

LITERATURE. — Crawfurd, R. P. Lancet, 1897, vol. ii. p. 1182. — Einhorn, M.
Medical Record, Sept. 16, 1899. — Faure. These de Paris, 1892. — Freeman. Archives
of Pediatrics, 1900, p. 81. — Glenard. Les ptosis viscerales. Paris, 1899. — Graham.
System of Practical Medicine, by Loomis and Thompson, vol. iii. p. 419. — M'Naughton,
Jones. Lancet, 1898, vol. i. p. 1327 (Heematemesis). — Packard. Trans. Coll. Phys.
Philad. 1896, p. 230. — Terrier et Auvray. Rev. de chirurg. 1897.— Treves. Lancet, 1900,
vol. i. p. 1339. — Vene. Joum. de medecine Intern. Oct. 15, 1898.

Functional Disease of the Liver

In the section on the physiology of the liver the functional importance
of the liver has been fully explained, and it is clear that any failure
in the discharge of these numerous duties must be followed by definite
symptoms.

Functional disturbance of the liver is undoubtedly a frequent occurrence
in common with functional disturbance of the other organs in the body.
The only questions are — Whether this functional disturbance is primary,
and whether the inadequacy is independent of any structural change.

So many conditions were formerly described as due to functional disease
of the liver, many of which had little or nothing to do with that organ ;
and this idea became firmly implanted in the lay mind, and therefore so
recklessly employed, that the tendency at the present time among medical
writers is rather to ignore the subject or to deny the existence of primary
functional disease of the liver. This swing of the pendulum to the opposite
extreme is due to the knowledge that the symptoms ascribed to functional
disease of the liver can in great part be explained as due to other factors,
such as indigestion, constipation, auto-intoxication, or to subacute congestion
of the organ; the latter condition being often secondary to intestinal
disturbance, or to an excessive ingestion of proteid food combined with an
imperfect excretion of waste products. In other words, the hepatic distur-
bances formerly regarded as primary functional insufficiency are in the vast
proportion of cases dependent on morbid processes occurring elsewhere, or
to morbid changes on the liver itself.

Thus, to consider the symptoms commonly referred to functional disease
of the liver. The distaste for food, dyspepsia, and flatulence are the expres-
sion of gastro-intestinal catarrh set up by poisonous or unsuitable food. The
icteric tint of the conjunctivas, the muddy skin, and the constipation or
diarrhoea, are explained by the spread of the gastro-duodenal catarrh to the
biliary papilla, and the slight obstruction to the flow of bile thus induced ;
or possibly to catarrh of the minute intrahepatic ducts set up by poisons
absorbed from the alimentary canal and subsequently excreted into the ducts.
The headache, giddiness, muscse volitantes, malaise, muscular debility, mental
depression, and irritability are due to the local action on the nervous system
of poisons absorbed from the alimentary canal. These toxic bodies are
either produced in such quantities that the liver fails to filter them off, or
more probably they act on the liver-cells and impair their vitality and
function, in either case the general circulation becomes flooded with toxic
bodies.

The piles, the feeling of weight in the right hypochondrium, and shoulder
pain, point to hepatic congestion, or even slight hepatitis, brought on by the
advent to the liver of digestive products in excessive amount and probably

484 LIVER, DISEASES OF

of altered (i.e. toxic) quality. This state of hepatic congestion is especially
apt to be set up in patients who have suffered from malarious fevers in the
tropics (vide Tropical Liver).

Nevertheless there can be no doubt that in some instances morbid
results are traceable to the functional disturbance of the liver, without its
being always possible to determine satisfactorily that this disturbance is
secondary. Thus in diabetes mellitus there is an excessive activity of the
glycogenic function, while in alimentary glycosuria the liver is unable to
discharge efficiently its function of stopping the sugar brought to it by the
portal vein. Thus diabetes mellitus and glycosuria may be regarded as
diseases due to functional disturbance of the liver, but these are not the
conditions ordinarily spoken of as functional liver disease.

It has recently been urged that puerperal eclampsia is in many cases
due to hepatic insufficiency, and that the renal symptoms are secondary to
a primary hepatic toxaemia. It is supposed that during pregnancy auto-
intoxication results from retention of the menstrual discharge, and that in
women who inherit a diminished hepatic activity and resistance the liver
fails to rise to the occasion, and that as a result of this insufficiency the
blood becomes loaded with poisons.

As has already been admitted, functional disorder of the liver no doubt
is responsible for many symptoms. The difficulty in regard to the subject
is to prove that the functional disturbance is primary in the liver, and not
secondary to disease or morbid factors elsewhere. The discussion is not a
mere academic exercise, but has a practical bearing on the treatment. Thus,
if it were thought that there was a primary failure of hepatic activity the
rational course would be to stimulate the organ. Whereas, if there was an
underlying and primary factor elsewhere, this should be attacked.

The difficulties about the recognition of primary functional disorders of
the liver may be best explained by considering some examples of the
conditions of which it has been or might be supposed to be the cause.

Lithsemia was described by Murchison as a condition of innate defect of
power, often hereditary, in the liver, in virtue of which its healthy functions
are liable to be deranged by the most ordinary articles of diet. As a
result of this hepatic insufficiency uric acid instead of urea was produced
in the liver and turned out into the blood. Among the results of
lithaemia Murchison enumerates such different conditions as dyspepsia,
constipation, gout, urinary calculi, biliary calculi, and acute and chronic
renal disease.

This theory is very far reaching, and offers an explanation of gout, in
fact many of the manifestations of lithsemia are those of irregular gout.

This theory of lithsemia depends on the assumption that the production
of uric acid instead of urea, occurs in the liver as the result of imperfect
oxidation. But more recent investigations show that the production of uric
acid is certainly not confined to the liver, but takes place elsewhere in the
body, being especially dependent on changes in lymphoid tissue and on
leucocytosis, the uric acid being derived from nuclein obtained from the
leucocytes. While according to Latham, -Kolisch, and Luff the formation
of uric acid occurs in the kidney. It is therefore too narrow a view of the
faulty metabolism of proteid material that results in an excessive production
of uric acid, to say that it depends on functional disorder of the liver to the
exclusion of the rest of the body.

An increase in the urates and uric acid in the urine is found in hepatic
disorder such as cirrhosis, congestion, and in conditions such as fever,
where the liver-cells might be affected by toxins in the blood, and so in-

LIVEE, DISEASES OF 485

capable of performing their proteolytic function. But even granting for
the moment that the formation of urea under normal conditions, and of
uric acid in excess in abnormal states, takes place in the liver, this process
is due to the functional disturbance that is not primary, but due to
structural modification, and secondary to morbid processes elsewhere.

It is, however, erroneous to conclude that even as a secondary effect the
faulty metabolism, takes place in the liver rather than elsewhere in the
body. Eor in grave disease of the liver, such as cirrhosis or extensive
malignant disease, the increase in the amount of uric acid in no way
corresponds with the view that its formation depends on an imperfect
metabolism of proteids by the liver ; while in cases of fever and toxaemia
the remainder of the body, being equally thrown out of gear, is liable to
faulty metabolism, one of the results of which might well be the production
of uric acid instead of urea.

Habitual high arterial tension and its accompaniments, such as migraine,
might be thought to depend on a failure of the liver to stop and destroy
the poisonous bodies that are carried to it from the intestines. The liver
undoubtedly exerts this important function of protecting the body from
auto-intoxication, but it is difficult to prove that failure in the discharge
of this duty leads to high arterial tension. Since in cases of extensive
disorganization of the liver, for example in cirrhosis, hepatic insufficiency
must exist, but the arterial tension is low and not raised. It is much more
likely that high arterial tension is, like gout, due to some general disorder
of metabolism of the body.

In cases popularly described as " biliousness," or " torpid ■" liver, where
there is indigestion, some hepatic pain, headache, slight icteric tingeing of
the conjunctivas, with a deficiency of colouring matter in the faeces, the
explanation is gastro-duodenal catarrh with slight catarrhal jaundice, and
not a primary diminution in the secretion of bile. In these cases it is
possible either that there is catarrhal swelling of the biliary papilla in the
duodenum, or that, as the result of gastro-intestinal indigestion, poisonous
products are carried to the liver, and then, when excreted into the bile ducts,
set up a certain amount of catarrh in the small intrahepatic ducts. This
leads to re-absorption of the bile with the poisons contained in it, which
pass into the general circulation and poison the body as a whole. Sir
Thomas Brunton has ingeniously shown that the proverbial bitter taste of
the bile is probably pathological, and due to the presence of poisons
absorbed from the bowel and then excreted into the ducts, and that in
health the bile is tasteless.

But because the ingenious conception of lithaemia and other time-
honoured views as to primary functional disease of the liver do not com-
mend themselves in the light of later knowledge, it does not follow that
hepatic insufficiency or inadequacy is a negligible factor.

It must be borne in mind that the liver, like other organs, must vary
greatly in different individuals as to its functional activity and reserve
power, and an amount of food products that could be satisfactorily dealt
with by the liver in one individual would in another be beyond the scope
of the liver. This difference in the inherent powers of the liver in different
persons is analogous to the differences in their muscular and mental power,
and the less powerful should not be described as suffering from functional
disease of their muscles or brain because they fail to accomplish the work
that their better developed companions have no difficulty with.

If, therefore, an individual consumes an amount of food that is excessive
for his powers of digestion, fermentation and auto-intoxication will result.

486 LIVEE, DISEASES OF

These poisons will impair the functional activity of the liver, and as a result
the poisons and the products of digestion will be allowed to pass into the
general circulation and give rise to the various toxic manifestations already-
referred to.

From what has gone before, it is evident that the well-known symptoms
ascribed to a torpid or inactive liver are chiefly due to factors which
secondarily interfere with the functional activity of the liver, and not to a
primary inadequacy of the organ.

Secondary Functional Disorder of the Liver

The symptoms have already been referred to on pp. 483-485, and a
few lines as to their treatment will now be given.

The treatment of the symptoms of secondary hepatic inadequacy must
therefore be directed to the causes, and not to the liver itself.

In the first place, the alimentary canal should be cleaned out ; this is
most satisfactorily effected by the use of the old-fashioned blue pill and
haustus sennse. The mercury drives out the bile out of the gall-bladder,
unloads the bile ducts, and by sluicing the common duct tends to remove
the causes of catarrh of its lower end. At the same time it acts as an
intestinal antiseptic, and inhibits excessive fermentation, and then puts a
stop to further auto -intoxication. The purgative action of these two
remedies removes the poisons from the body.

Plenty of water should be taken so as to wash out the poisonous
products from the circulation and stimulate the functional activity of the
kidneys.

During the existence of symptoms a liquid diet, of which milk is the
staple, should be adopted, while alcohol in any form should be rigidly
avoided.

In the second place, the patient should be warned to avoid the forms of
food likely to set up intestinal catarrh and fermentation. The articles of
food that must be avoided as indigestible will, of course, vary in individual
cases, but generally speaking the following should be avoided : — Concen-
trated and highly spiced soups or essences, pork, duck, hare, game, made
dishes, sauces, melted butter, tea cakes, crumpets, cheese, and much proteid
food. Alcohol should be taken in great moderation, and chiefly in a diluted
form, as whisky, or claret and water ; while beer, porter, champagne, sherry,
port should be prohibited.

Exercise is important, and should be of an active nature ; horse exercise
is the best, bicycling useful, and walking the least effective. The skin
should be got to act, and Turkish baths are useful for this purpose. A
visit to spas such as Carlsbad, Marienbad, Vichy, or Ems, and a regulated
course of treatment there, will benefit the patient.

As to the prognosis, the digestive disturbances which give rise to these
symptoms are the same that lead to cirrhosis, and indeed the symptoms of
" functional disease " of the liver may in some instances be the early
manifestations of cirrhosis.

LITERATURE. — Brunton. Clinical , Journal, 10th Jan. 1900.— Hunter. Allbutt's
System of Medicine, vol. iv. — Murchison. Diseases of the Liver.

Diseases of the Hepatic Artery

Diseases of Hepatic Artery —

Embolism

Arteriosclerosis .

487

Aneurysm .

Thrombosis ....

487

Enlargement

487
487
487

LIVER, DISEASES OF

487

Hepatic Veins —
Thrombosis .
Embolism

488
488

Stricture .... 488

Suppurative Inflammation . 489
Lymphatic Vessels —

Glands in Portal Fissure . 489

Arteriosclerosis. — A certain amount of change occurs in the hepatic
artery in arteriosclerosis, and no doubt may dispose to the rare events —
thrombosis and aneurysm.

It is, however, noticeable that arteriosclerosis of the hepatic artery does
not lead to any change in the liver comparable to a granular kidney.

In cases of hsemochromatosis there is endarteritis of the hepatic artery,
while in the neighbourhood of gummata and in syphilitic disease of the
liver endarteritis obliterans is found.

Thrombosis. — Thrombosis of the hepatic artery has very rarely been
noted, and is a pathological curiosity. Lancereaux refers to a rather
doubtful case in a man aged 65, who died with arteriosclerosis and gangrene
of the feet.

Embolism. — Like thrombosis few cases are on record, probably because
the condition of the hepatic artery is rarely investigated.

As a result of embolism of the main trunk necrosis of the liver has
been noted both in man (Chiari, Lancereaux) and in animals ; in a case that
I had an opportunity of seeing, with Dr. C. Ogle, of embolism of the bifurca-
tion of the artery, the liver showed white infarcts, but was not completely
necrosed. Experimentally ligature of the hepatic artery slows the flow of
bile, and thus disposes to cholangitis. Septic emboli give rise to multiple
abscesses. Emboli of the small branches occur in melanotic sarcoma.

Aneurysm of the Hepatic Artery. — There are about 30 recorded
examples of hepatic aneurysm.

Situation. — Aneurysms may occur on the main trunk of the artery, at
the bifurcation, or on its main branches, in which case the aneurysm may
be either in the substance of the liver or outside it, just in the portal
fissure. Symmetrical aneurysms on the two branches of the hepatic artery
have been met with. An aneurysm has been found in the wall of an
hepatic abscess ; this lesion was evidently due to ulceration attacking the
artery from without, and is comparable to the production of an aneurysm
in the walls of vomicae in pulmonary tuberculosis. Small intrahepatic
aneurysms may occur in great numbers in the rare condition periarteritis
nodosa.

Causation. — They may be due to embolism, arteriosclerosis, and in rare
instances to traumatism.

Symptoms. — Pain resembling that of biliary colic is generally present,
while jaundice due to pressure on the bile ducts may further increase the
clinical resemblance to cholelithiasis. In other cases the aneurysm ruptures
either into the bile duct, peritoneum, or duodenum ; on the latter event it
may resemble a duodenal ulcer.

Diagnosis is very difficult. In the absence of pulsation the symptoms
suggest gall-stones. If pulsation is present the commoner condition of
aortic aneurysm would be more likely to suggest itself.

Enlargement of a compensatory nature of the hepatic artery is seen in
some cases of new growth, cirrhosis, and in thrombosis of the portal vein of
some standing.

LITERATURE. — Embolism : Chiari. Zeitschrift. f. Heilkunde, Bd. xix. S. 507.—
Lancereaux. TraiU des maladies du foie et du pancreas, 1899. — Ogle, C. Trans. Path.
Soc. xlvi. p. 73. Aneurysm: Caton. Trans. Clin. Soe. vol. xix. p. 275. — Irvine, P.
Trans. Path. Soc. vol. xxix. p. 128. — Mester. Zeitschrift. f. klin. Med. 1895, Bd. xxviii.

488 LIVER, DISEASES OF

— White, Hale. Brit. Med. Joum. 1892, vol. i.j p. 223. — Dreschfeld. Encyclopcedia
Medica, vol. i.

Diseases of the Hepatic Veins

Thrombosis of the hepatic veins is somewhat rare, and is hardly likely
to be diagnosed correctly during life.

Causes. — It may be secondary to changes in the liver, such as the
extension of new growth, the softening down and discharge of adenomata
(vide p. 529) into the veins, or the spread of inflammation from a focus in
the liver to the walls of the vein. Thrombosis may be secondary to stricture
of the trunks of the hepatic veins (vide infra). In rare instances throm-
bosis may spread from a parietal clot not completely obstructing the inferior
vena cava, or be secondary to obliteration of that vessel. In exceptional
instances it is met with as part of a widespread thrombotic process.

Results. — A condition of chronic venous congestion or nutmeg liver with
the rapid development of ascites follows thrombosis of the hepatic veins.
Occasionally the stagnation thus induced may set up thrombosis of the
portal vein.

Embolism. — Embolism of the hepatic veins can only occur when the
embolus travels against the blood stream and enters the hepatic veins from
the inferior vena cava, or in other words be retrograde. Eetrograde embolism
of veins is very rare; when it occurs it is more frequently seen in the
hepatic veins, since they are not protected by valves, and are so close to the
heart that fragments of growth or thrombus may drop into their orifices
either from the inferior vena cava or the heart and superior vena cava.
Welch, in his article on embolism, quotes examples of fragments of new
growth being found in the hepatic veins in cases where the primary growths
were in the abdomen and thyroid body.

It seems probable that, in cases of cranial suppuration with secondary
abscesses in the liver without any abscesses in the lungs, the micro-organisms
may drop down the jugular vein, superior vena cava, right auricle and
inferior vena cava into the orifices of the hepatic veins, and so infect the
liver. The production of retrograde embolism probably depends on the
temporary stagnation or reversal of the direction of the blood flow. Thus,
if a thrombus was passing up the inferior cava and a violent expiratory
effort or cough occurred at the moment when it was opposite the openings
of the hepatic veins, the embolus might be carried into the liver.

LITERATURE.— Welch. Allbutt's System of Medicine, vol. vi. p. 232.

Stricture and Stenosis. — Stricture may be due to the contraction of
adhesions around the hepatic veins near their entrance into the inferior
vena cava. This may be due to changes starting in or outside the liver.
Gummatous inflammation may spread to the walls of the vein and set up
peri- and endophlebitis, the latter leading to narrowing of the lumen
(endophlebitis obliterans). This may occur in congenital or in acquired
syphilis. Syphilis;,seems a probable factor in the production of most of the
recorded cases of this rare condition. Probably chronic inflammation due
to other causes may bring about a similar narrowing of the hepatic veins.
The hepatic veins may be pressed upon from without by new growths,
tumours, etc., and so be narrowed.

The symptoms referable to stricture of the hepatic veins are much the
same as those of thrombosis of the veins, to which it may give rise.

LIVER, DISEASES OF 489

LITERATURE.— Chiaei. Beitrage z.path. Anat. u. z. allgem. Path. Bd. xxvi.— Churton.
Trans. Path. Soc. vol. 1. p. 145. — Ererichs. Diseases of Liver, vol. ii. p. 432. —Gee.
St. Bartholomew's Hosp. Beports, vol. vii. p. 144. — Kelynack. Med. Press and Circular,
June 23, 1897. — Lazarus-Barlow. Trans. Path. Soc. vol. 1. p. 147. —West. Trans.
Path. Soc. vol. xlii. p. 155.

Suppurative inflammation is more likely to spread to the hepatic veins
in hepatic abscess, etc., than to the branches of the portal vein, since the
latter are more protected by Glisson's capsule. In suppurative phlebitis of
the hepatic veins secondary abscesses in the lungs and general pyaemia are
of course likely to follow.

Diseases of the Lymphatic Vessels of the Liver

Very little is known about the morbid conditions of the lymphatic
vessels of the liver. They are affected when tuberculosis and lymphadenoma
attack the liver, and can hardly escape in acute cholangitis and pylephlebitis.
In tuberculous and chronic peritonitis and perihepatitis the inflammatory
process spreads inwards from the capsule, possibly by means of the
lymphatics, for some little distance.

New growth may sometimes be seen working its way into the liver
against the lymph stream along the lymphatics of the portal fissure ; more
commonly the glands in the portal fissure become infected secondarily to a
growth in the liver, the infecting cells travelling in the normal direction
along the lymphatic vessels.

Distension of the lymphatic vessels in the portal spaces occasionally
occurs from pressure ; it has also occurred in hepatoptosis from torsion of
the lymphatics around the bile duct.

In diabetic lipsemia I have seen the lymphatics of the portal spaces
graphically mapped out by the contained fat.

The Lymphatic Glands in the Portal Fissure. — Any enlargement of
those glands is of importance, inasmuch as pressure may thus be exerted on
the bile ducts and jaundice set up. Thus it has been thought, but probably
without sufficient reason, that the jaundice which in rare instances occurs in
the roseolous stage of syphilis may be due to swelling of the glands in the
portal fissure. Enlargement of the portal glands may occur in lardaceous
disease and leukaemia, but cannot be credited with producing jaundice or
ascites by compression of the bile duct or portal vein in these diseases.

Enlargement of the portal lymphatic glands may be due to various con-
ditions, chiefly inflammatory, inside the liver, such as abscess, pylephlebitis,
suppurative cholangitis, tubercle, hypertrophic biliary cirrhosis, and primary
carcinoma.

As already mentioned, new growth may extend into the portal fissure
along the lymphatic vessels against the flow of lymph, and occasionally
infiltration of the portal lymphatic glands may be secondary to carcinoma
in the peritoneal cavity ; when this has occurred jaundice may result.

Chronic Venous Congestion of the Liver

Chronic Venous Engorgement
op Liver —

Etiology .... 490
Morbid Anatomy and His-
tology .... 490
Physical Signs and Symp-
toms .... 491
Synonyms. — Nutmeg Liver, Cardiac Liver, Cyanotic Atrophy, Bed Atrophy,

Hepatic Asystole.

Termination and Pro-
gnosis .... 492

Diagnosis .

Treatment
Hepatic Pseudo-Cirrhosis
Infarcts .

492
492
493
494

490 LIVEB, DISEASES OF

This condition is almost always secondary to obstructive heart disease,
especially of the mitral valve, or lung lesions, such as chronic bronchitis,
emphysema, and some forms of pneumoconiosis. The symptoms due to the
hepatic condition are, as a rule, merely added on to those of the primary
disease ; in some instances, however, the former are more prominent than
those of the primary lesion, and to these cases the term " hepatic asystole "
has been applied.

Etiology. — Any causes that lead to backward pressure and tricuspid
regurgitation will produce chronic engorgement of the inferior vena cava,
the hepatic veins, and their branches — the sub-lobular and intra-lobular veins.
Mitral stenosis, dilatation of the left ventricle, mitral regurgitation from
whatever cause, and obstruction to the pulmonary circulation, such as
emphysema, are the common causes of tricuspid regurgitation and chronic
venous engorgement of the liver. Tricuspid stenosis is rare ; when it does
occur it is always combined with, and secondary to, mitral stenosis. When
it is present the hepatic engorgement is very marked.

It is possible that tumours or new formations, such as a hydatid cyst,
gumma, or cicatrices, might compress the inferior vena cava between the
entrance of the hepatic veins and the right auricle. Another conceivable
cause is kinking of the inferior vena cava, from displacement of the heart
caused by the presence of a large pleural effusion. Obstruction at the ori-
fices of the hepatic veins due to cicatricial contraction of gummatous tissue
or to syphilitic change in the walls of the veins — both of them rare lesions
(vide p. 488) — may induce a nutmeggy condition of the liver. Lastly, new
growths or hydatid cysts in the substance of the liver may produce local
areas of chronic venous engorgement.

Morbid Anatomy. — The liver is usually somewhat enlarged, though not
so much as in life. Its size depends on the amount of blood in it; further, the
organ is much more distensible in life than after death, when its protoplasm
coagulates or enters into rigor mortis. In advanced cases the liver-cells
undergo atrophy, and the liver tends to become smaller. Externally it is of
a mottled purple colour, and the subcapsular veins, seen as slight depressions
in its surface, show up from atrophy of the surrounding liver substance.
Sometimes there is subcapsular fibrosis (replacement fibrosis), which must be
distinguished from perihepatitis. When ascites has existed for some time
the capsule may be opaque. In rare cases chronic peritonitis spreads from
an adherent pericardium to the capsule of the liver ; the condition then
becomes chronic universal perihepatitis.

On section the appearance is like that of a cut nutmeg ; the sub-lobular
veins and their branches — the intralobular veins — are dilated, and being
full of blood, appear as dark purple spots or streaks corresponding to their
transverse or longitudinal section. Apart from these venules the liver-
cells, being stained with bile and infiltrated with fat, appear of a yellowish
white colour. This contrast gives rise to the name " nutmeggy " liver.
This nutmeggy appearance may be fine or coarse ; the latter condition is
less characteristic.

The hepatic veins are dilated and their walls opaque and somewhat
thickened, the liver tissue around being somewhat atrophied and compressed.
Oppinet has suggested that the incidence of hepatic asystole or marked
hepatic phenomena in a case of morbus cordis is determined by an anatomi-
cal condition of the hepatic veins at their entry into the inferior vena
cava, which is congenital in origin and fairly common. But it seems more
natural to regard these changes as secondary to backward pressure.

Occasionally there is some sporadic fibrosis of the liver, and it has been

LIVER, DISEASES OF 491

thought that chronic venous congestion causes cirrhosis. It is true that as
the result of atrophy of the liver-cells the fibrous tissue becomes more
prominent, but genuine cirrhosis is not due to chronic venous engorgement
of the organ pure and simple. The state of chronic portal congestion may,
and often does, lead to intestinal catarrh, and by the consequent formation
of poisons some cirrhosis in the liver might be expected much more often
than is actually the case. In long-standing cardiac disease a considerable
amount of alcohol is often given, which again might lead to cirrhosis. On
the other hand, dilatation of the heart due to alcoholic excess may induce
chronic venous engorgement in a liver already cirrhotic. Still, with all
these possibilities the liver is, as an actual fact, very seldom genuinely
cirrhotic in chronic venous engorgement.

Histology. — The intralobular veins are dilated, and their capillaries are
two or three times larger than normal from distension with blood. This
dilatation spreads outwards through the lobule as the condition of passive
engorgement becomes more marked.

The liver-cells in the centre of the lobule are atrophied from pressure
and malnutrition, inasmuch as their supply of oxygen is curtailed by the
venous stagnation. They degenerate and contain hsematoidin, an iron-
free product, derived from the red blood corpuscles. This pigmentation
must be distinguished from the infiltration of the cells in the peripheral
zone of the lobule with hsemosiderin, an iron-containing pigment, seen in
pernicious ansemia. The cells in the peripheral parts of the lobule undergo
fatty change. As a result of the atrophy of the liver-cells the supporting
fibrous framework of the liver becomes more prominent, and in some
instances sporadic cirrhosis is seen. This fibrosis may be especially marked
directly underneath the capsule of the liver ; to the naked eye this gives an
appearance not unlike that of universal chronic perihepatitis.

Physical Signs. — The liver is enlarged, uniformly smooth, and tender.
The tenderness is due to the distension and stretching of the capsule. The
size of the liver varies considerably from time to time, and depends on the
condition of the right side of the heart ; efficient cardiac treatment may,
therefore, rapidly have a marked effect.

In a small percentage of cases the liver pulsates with each beat of the
heart. In 235 cases of tricuspid regurgitation it was present 15 times,
and in 87 cases of tricuspid stenosis on 8 occasions (Pitt). True expansile
pulsation, compared to that of an accordion, is best felt with one hand in
the right loin and the other over the anterior surface of the liver. It is
due to the blood being driven into the hepatic veins with each beat of the
heart. It should be remembered that not uncommonly the liver receives a
jog from the contraction of a dilated or hypertrophied right ventricle, but
there is no expansion of the organ. Similarly in rare cases pulsation may
be communicated to the liver from an abdominal aneurysm. In expansile
pulsation the blood regurgitates more easily into the left lobe, which
therefore pulsates more freely.

The enlarged liver may push up the right leaflet of the diaphragm, and
lead to some collapse of the case of the right lung, with dulness and absence
of breath sounds. In some instances pleural effusion may occur.

Sometimes as a result of infection there may be some acute perihepatitis,
with friction audible or even palpable over the liver.

The urine is concentrated, high coloured, and lithatic. It may contain
excess of urobilin, which has been regarded as a sign of hepatic insufficiency
(Hayem). There is sometimes albuminuria without any gross lesion of the
kidney, due in all probability to chronic venous congestion impairing the

492 LIVEE, DISEASES OF

vitality of the epithelium covering over the glomerular tufts. As a result
albumin is allowed to leak into the cavity of Bowman's capsule. Ali-
mentary'glycosuria has in rare instances been noticed.
Auto-intoxication is favoured in several ways :

(1) The liver being ill-nourished, from venous stagnation impeding the
advent of arterial blood, does not destroy poisons absorbed from the
alimentary canal so completely as in health. Toxic bodies, therefore, pass
into the general circulation.

(2) Portal congestion favours the manufacture of toxic products in the
intestines ; hence poisons in increased quantity are carried to the liver.

(3) Chronic venous engorgement of the kidneys interferes with proper
renal excretion.

The symptoms referable to chronic venous engorgement of the liver are
heaviness and discomfort in the right hypochondrium. Definite pain may
be met with when perihepatitis is implanted on the engorged liver. The
chronic portal engorgement gives rise to slow and feeble digestion, loss of
appetite, dyspepsia, flatulence, and tympanites ; while gastro-intestinal
catarrh is readily set up. The condition of the alimentary canal interferes
with assimilation, and the patient's general nutrition is impaired ; this is
especially the case in growing children in whom mitral disease with back-
ward pressure on the portal system may be considered as a wasting disease.

Extension of catarrh to the biliary papilla may occur. The slight
icteric tint of the conjunctiva and skin, so characteristic of advanced mitral
disease, is due either to this cause or to slight cholangitis of the small
intrahepatic ducts. This jaundice is slight and not due to complete
obstruction. Occasionally a terminal infection, leading to acute degenera-
tive changes in the liver-cells and icterus gravis, may carry the patient off.
Orthopncea and dyspnoea are mainly dependent on the primary lesion, but
in hepatic insufficiency there may be dyspnoea of a ursemic type due to
auto-intoxication.

(Edema of the feet and ascites are common accompaniments of this
hepatic condition ; in 235 cases of tricuspid regurgitation oedema occurred
in 200 and ascites in 140 (Pitt). The ascitic fluid is usually straw-coloured,
but has been noted to be chyliform.

Termination. — Death is commonly due to increasing cardiac failure, or
to some terminal infection setting up pneumonia, pleurisy, etc. Infection
may fall on the liver itself, and give rise to acute degenerative changes in
the liver-cells and icterus gravis.

The prognosis depends on the character of the primary cause ; when
the chronic venous engorgement of the liver ensues in the course of heart or
lung disease of old standing, the outlook is naturally bad. If secondary to
more acute dilatation the outlook is more hopeful.

Diagnosis. — When the cardiac lesion is definitely recognised no difficulty
arises. But in the cases described as hepatic asystole, where attention is
focussed on the liver, the condition may be thought to be one of cirrhosis,
or possibly malignant disease, with secondary cardiac failure. The smooth-
ness of the liver, the absence of dilated veins on the abdominal wall, and of
any splenic enlargement, and the effect of cardiac tonics, are in favour of
passive congestion of the liver and against cirrhosis. The smoothness of the
surface, the slighter degree of enlargement, the diminution in size produced
by appropriate cardiac treatment, together with absence of severe pain and
cachexia in nutmeg liver, will usually prevent any difficulty in the diagnosis
from malignant disease of the organ.

Treatment should be directed to the primary lesion, whether cardiac or

LIVEE, DISEASES OF 493

combined pulmonary and cardiac disease. Digitalis is the most efficacious
drug, and may be combined with or replaced by strophanthus in cases of
mitral stenosis. A pill containing digitalis, squills, and mercury is a valu-
able compound, and may be given at the same time that citrate of caffeine
is administered by the mouth.

The hepatic engorgement may be successfully treated by purgatives,
such as the old-fashioned blue pill and haustus sennse, or by the administra-
tion of 2 to 4 drachms of sulphate of magnesia in hot water after an
abstinence from liquid for some hours (Matthew Hay's method). Paracen-
tesis of the abdomen may be necessary.

For insomnia hypodermic injection of morphia is the most satisfactory
remedy ; if there be respiratory distress from bronchitis its administration
is contra-indicated, and paraldehyde or chloralamide should be tried.

The diet should be simple and nutritious, and not contain too much fluid,
as this would tend to aggravate the often already water-logged condition.

LITERATURE.— Hanot. Bull, de la soc. m&d. des h6p. 1895, p. 409.— Pitt. Allbutt's
System of Medicine, vol. v.

Hepatic Pseudo-Cirrhosis
Synonym. — Pericardial Pseudo-Cirrhosis.

Under this title a number of cases have been described that are prac-
tically only chronic venous engorgement of the liver. Pick describes the
clinical aspect as being rather that of cirrhosis, inasmuch as ascites is a
prominent feature, while oedema of the legs is slight or may be absent.
The pathological change is adherent pericardium, and not valvular disease
of the heart, with subsequent circulatory disturbance in the liver, which is
in a state of nutmeggy atrophy, showing some increased fibrosis without any
perihepatitis.

The adherent pericardium may be the result of rheumatic, or more
rarely tuberculous inflammation ; in the latter case the liver may be also
tuberculous. The adhesions dilate the right auricle, inferior vena cava, and
hepatic veins, and thus render hepatic asystole permanent.

The condition is thus one of exaggerated nutmeg liver, and the stress
of the backward pressure falls on the peritoneal cavity: the veins of the
legs thus suffer less from chronic engorgement, and oedema of the feet is
not induced so readily as in ordinary cardiac lesions. It is possible that at
the time of the primary pericarditis inflammation spreads to the mouths of
the hepatic veins, and by weakening their walls leads to dilatation and to a
freer entry of blood into them, and that this condition, once established,
remains permanently. It is thus possible to explain the connection of
adherent pericardium with nutmeg liver and marked ascites, accompanied
by less prominent oedema of the legs. I have examined some of these
cases, expecting to find an extension of fibrosis from the adherent pericar-
dium along the hepatic veins into the substance of the liver, but have
never found any perivenous fibrosis, though the inner walls of the hepatic
vein and inferior vena cava are opaque and thickened as is commonly seen
in cases of backward pressure.

The liver shows marked chronic venous congestion (ramose atrophy)
with irregularly scattered areas of fibrosis. There are signs of hyperplasia
of the connective tissues and limited areas exactly like multilobular
cirrhosis, but, taken as a whole, the amount is scanty and large areas may
be quite free from fibrosis. The condition may be summed up as advanced
chronic venous congestion with sporadic cirrhosis. There may be a thin
layer of cirrhosis immediately under the capsule, forming a kind of second

494 LIVER, DISEASES OF

or inner capsule for the organ, and looking to the naked eye like peri-
hepatitis (compare nutmeg liver, p. 491).

Prognosis and Results. — When the condition of hepatic pseudo-cirrhosis
has become established the prognosis is very bad.

Tuberculous peritonitis may supervene as a secondary result ; this was
proved to be the sequence of events in a case recorded by Nachod, where
laparotomy a year before death proved the absence of tubercle at that time.
Secondary tuberculous infiltration of the portal spaces may then occur. The
term cardio-tuberculous cirrhosis has been applied to cases where advanced
chronic venous congestion and tuberculosis of the liver are combined.
These cases, which are chiefly met with in children, are associated with
more advanced tuberculous disease elsewhere, especially in the peritoneum
and pleura. These conditions of hepatic pseudo-cirrhosis and cardio-
tuberculous cirrhosis are closely allied both to nutmeg liver and to the cases
of general perihepatitis secondary to adherent pericardium. Clinically the
chief difference from nutmeg liver is the absence of any signs of cardiac
valvular disease. The treatment, however, is that of chronic venous
engorgement of the liver, viz. cardiac tonics and diuretics. The treatment
suitable for cirrhosis is of no use in these conditions.

LITERATURE.— Pick. Zeitschft. f. klin. Med. Bd. xxix. S. 6.— Nachod. Prag. med.
Wochen. 1898, S. 330, June 30. — Venot. These de Paris, 1896. — Moizaed and Phtjlpin.
Archiv. de midecine des en/ants, Aug. 1899 (Cardio-tuberculous Cirrhosis). — Traite" des maladies
de I'enfance (Geanchee, Comby, Maefan), tome iii. p. 220 (Cardio-tuberculous Cirrhosis).

Infaects in the Liver

Infarction of the liver is rare, but appearances resembling infarcts in
other organs undoubtedly occur, and are probably less infrequent than is
thought. Lazarus-Barlow has collected 32 examples — of these 28 were
hemorrhagic and 4 anaemic. They resemble pulmonary apoplexies, and
differ from infarcts in other organs in several ways. Thus in both the
lung and liver there is a double blood-supply, the bronchial and pulmonary
arteries, and the hepatic artery and portal vein respectively; like pul-
monary apoplexies, hepatic infarcts are usually hemorrhagic, do not show
coagulation necrosis, or project above the surface when recent, and are not
succeeded by depressed cicatrices, thus contrasting with the typical infarcts
in the spleen and kidneys, which are possessed of end arteries. For these
reasons it might be convenient to speak of these appearances in the liver as
" pseudo-infarcts," inasmuch as they are not in the strict sense of the term
infarcted (stuffed or swollen).

Infarcts in the liver have been met with most often in association with
portal thrombosis or embolism of the branches of the portal vein. Obstruc-
tion of the intra-hepatic branches of the portal vein by new growth, and
embolism or thrombosis of small intra-hepatic branches of the portal vein,
may also appear to be a cause ; while combined portal and hepatic vein
thrombosis (Pitt), embolism of the hepatic artery (Ogle, Chiari), severe
traumatism, and retrograde embolism of the hepatic veins, have been found
in isolated instances. Infarcts of the liver have been described in Cir-
rhosis and in Nutmeg Liver (Bonome). None of these conditions,
however, are essential to or necessarily followed by infarction of the liver ;
some other factor, possibly a toxemic state, is requisite for the formation of
the infarction.

The hemorrhagic infarcts resemble nevi to the naked eye, and are not
raised above the surface of the organ. The capillaries are dilated and the

LIVER, DISEASES OF 495

liver - cells atrophied, but not necrosed or involved in the process of
coagulation necrosis seen in infarcts elsewhere.

The anremic infarcts resemble, only they are more sharply defined, the
anaemic patches often seen in the liver in infectious disease. The capillaries
are empty.

Infarction of the liver has no clinical aspects, and is only of pathological

interest.

LITERATURE.— Bonome. Rev. g&nir. de path, intern. 1900, p. 70.— Chiari. Zeit-
schrift.filr Heilkunde, Bd. xix. S. 475. — Lazarus-Barlow. Brit. Med. Journal, 1899, vol. ii.
p. 1342. — Ogle, C. Trans. Path. Soc. vol. xlvi. p. 73. — Pitt. Trans. Path. Soc. vol. xlvi.
p. 75. — Welch. Allbutt's System of Medicine, vol. vi. p. 280. — Wooldridge. Trans. Path.
Soc. vol. xxxix. p. 421.

Biliary Cirrhosis

1. Hypertrophic Biliary Cir-
rhosis .... 495

2. Obstructive Biliary Cir-
rhosis .... 502

This condition may conveniently be considered under two distinct
heads : —

(1) Hypertrophic biliary cirrhosis.

(2) Obstructive biliary cirrhosis.

Hypertrophic Biliary Cirrhosis

Synonyms. — Hypertrophic Cirrhosis with Chronic Jaundice ; Hanot s
Disease; Biliary Cirrhosis proper.

It is sometimes spoken of as hypertrophic cirrhosis. This is to be
avoided, since it is likely to lead to confusion as there are several other
kinds of large cirrhotic livers ; in common or portal cirrhosis the organ is
often much enlarged, a fatty cirrhotic liver is of very considerable size, and
the pigmented cirrhotic liver in hemochromatosis is also entitled to the
adjective hypertrophic.

Definition. — The disease is characterised by chronic jaundice, fever,,
absence of ascites, enlargement of the liver and of the spleen ; it usually
occurs in young persons. There is no gross obstruction to the larger bile
ducts ; histologically the cirrhosis is more monolobular than in ordinary
portal cirrhosis.

History. — Although the condition was recognised by Requin in 1846,.
by Todd eleven years later (1857), and by Hayem (1874), it did not attract
any attention until Hanot (1875) sharply struck out the disease in his
thesis on Hypertrophic Cirrhosis with Chronic Jaundice. In 1893 Kiener
suggested that the disease should be called Hanot's disease. Somewhat
different forms of hypertrophic biliary cirrhosis have been described of late
years in France, by Hayem, and by Gilbert and Fournier, and Gilbert and
Castaigne, and discussion has arisen as to the channel by which the cause
of the disease reaches the liver.

Of late years the opinion has been growing that the description given by
Hanot was too crystallised, and that few cases conformed to the rigid type
he erected. It must, however, be admitted that there is a very distinct
difference between common cirrhosis and the condition to be described as
hypertrophic biliary cirrhosis. Transitional forms between them are met
with just as there are between the arterio-sclerotic kidney and that of
chronic parenchymatous nephritis ; but it would be incorrect to assume
that they are different manifestations of a process that is essentially one
and the same.

496 LIVEE, DISEASES OF

Etiology. — Age. — It is commonest between the ages of 20 and 30, and
is rare after 40, thus contrasting with common cirrhosis, in which the
average age is about 48 years. A number of cases are met with in young
children ; Gilbert and Fournier have described a special juvenile type.

Sex. — In children the incidence of the disease falls equally on the two
sexes, but apart from the juvenile cases, it appears that males are more
often attacked. In Schachmann's 26 cases only 4 were females.

Heredity. — The disease is sometimes met with in several members of
one family when exposed to the same conditions. In Brahmin infants
around Calcutta a form of cirrhosis described as biliary is very common, and
is especially apt to attack members of the same family ; thus, as many
as 14 children of the same parents have died of it one after another.

In this country Dreschfeld has met with the disease in two brothers, and
Osier has had a similar experience in America.

It is interesting to note that in other members of the same family, who
have no other manifest signs of the disease, the spleen may be found to be
enlarged ; this is analogous to the loss of knee-jerk in apparently healthy
members of a family containing some children affected with hereditary
ataxia.

Alcohol. — The antecedents of patients with hypertrophic biliary
cirrhosis sometimes include heavy drinking, but there is no reason to
regard alcoholism as related to the disease in the same way as it is to
common cirrhosis. It may safely be said that alcoholic excess does not
protect against biliary cirrhosis, but on the contrary disposes to infection
by reducing the resisting power of the body as a whole, and of the liver in
particular. In the case of biliary cirrhosis in Brahmin infants alcohol can
play no part. Of two brothers whose cases were recorded by Dreschfeld, one
was a hard drinker, while the other was temperate. Boix has recently put
forward the view that the infection is introduced into the body in water,
and it has been thought that cold and damp houses favour the occurrence
of the disease.

Malaria in like manner has been an antecedent condition in some cases,
but in the great majority of instances this can be put out of court.

There is no evidence that syphilis causes the disease.

The disease has been noticed to start after typhoid fever (Boinet) in a
few instances.

Hanot originally regarded the initial lesion as being a catarrhal
inflammation of the small bile ducts. Such a lesion might originate in the
minute ducts, and be due to a poison reaching them by the blood, as in
experimental poisoning by toluylenediamine, in other words be a descending
cholangitis. The condition of the liver would then be a local manifestation
of a general infection. In favour of this infective origin for hypertrophic
biliary cirrhosis are the following facts : —

(1) The frequency of fever.

(2) The considerable splenic enlargement which indeed may precede, or
be more marked than that of the liver.

(3) The existence of leucocytosis.

(4) Glandular enlargement not only in the portal fissure, but sometimes
in distant parts of the body.

The enlargement of the spleen, which may precede and be more promi-
nent than the hepatic enlargement, is best explained as due to an infective
agent in the blood, which at the same time that it leads to changes in the
liver, settles down in the spleen, and there multiplies and produces poison.
It is possible that the poison thus poured into the portal vein sets up a

LIVER, DISEASES OE 497

secondary portal cirrhosis on the top of the already existing biliary
cirrhosis, and thus accounts for the mixed type of cirrhosis so often found
histologically in the livers of long-standing cases of biliary cirrhosis.

The alternative view is that hypertrophic biliary cirrhosis is due to a
local infection of the bile ducts from the duodenum — an ascending cholan-
gitis. According to this theory it would be analogous to broncho-pneumonia
following bronchitis of the larger tubes. Gilbert and Eournier regard it as
an ascending infection from the intestine, and due to the prolonged action
of the colon bacillus. The enlargement of the spleen is regarded as
secondary to the local and primary infection of the liver, and due to micro-
organisms or their poisons absorbed from the infected bile ducts.

Against the view that it is an ascending infection might be urged the
comparative infrequency of dyspepsia as an antecedent symptom, and
the fact that a catarrhal condition of the duodenum is not found at the
autopsy. The fact that the spleen is sometimes found to be enlarged before
the liver, and may even be larger than the liver, is also against this theory,
and in favour of the primary factor being a general hsemic infection.

On the whole, it seems more probable that hypertrophic biliary cirrhosis
is due to a hsemic infection of a chronic nature leading to inflammatory
changes in the liver, than that it is an ascending infection of the bile ducts
from the duodenum.

Congenital obliteration of the bile ducts (vide vol. iv. p. 47), which is
associated with very marked monolobular cirrhosis of the liver, can be
regarded as due to a poison circulating in the blood, which, when excreted
into the small bile ducts, sets up a descending cholangitis. This cholangitis
leads to union of the inflamed surfaces of the larger ducts, analogous to
obliteration of the vermiform appendix after catarrhal appendicitis.

Possibly among the different forms of hypertrophic biliary cirrhosis
there are some cases due to an ascending infection, though the majority are
like scarlatinal nephritis, due to a poison reaching them by the general
circulation.

A question which cannot at present be answered is whether poisons
reaching the liver by the portal vein ever set up the lesions of hypertrophic
biliary cirrhosis. As shown by experiments with toluylenediamine, poisons
in the general circulation reaching the liver are excreted into the small
bile ducts, and set up inflammation of the smaller ducts ; this is analogous
to hypertrophic biliary cirrhosis. As far as we know, poisons arriving by
the portal vein tend to produce common (portal) cirrhosis. An exception,
however, must be made for congenital syphilis (vide p. 542), where the
fibrosis is intercellular.

Bactekial Origin. — Although a specific origin for the disease has been
anticipated, no microbic cause has been established. The colon bacillus has
been found in blood withdrawn by puncture from the liver during life, and
subsequently in the liver and spleen in the same case (Gilbert and
Fournier). But further evidence must be brought forward before the colon
bacillus can be regarded as the specific cause. Hayem, in a class of cases
he describes as chronic infectious jaundice with splenic enlargement and
exacerbations, but which is very closely allied to, if not the same disease as
hypertrophic biliary cirrhosis, found the diplococcus pneumonia? in blood
aspirated from the spleen during life. The absence of suppuration and
chronicity of the disease are against its being clue to pyogenetic cocci.

Probable though the bacterial origin of the disease is, further research
is urgently required before it can be considered as proved.

Morbid Anatomy. — The liver is enlarged and weighs from 80 oz. to
vol. vi . 32

498 LIVEE, DISEASES OF

8 lbs. or more ; it is uniformly increased in size. Not infrequently there
are perihepatitic adhesions, but apart from them the surface of the organ is
almost smooth and does not show the gnarled aspect of common cirrhosis.
Sometimes from secondary portal cirrhosis the surface becomes slightly
irregular. It is of a dark green colour, and on section is firmer than natural.

The portal vein and the hepatic artery show no signs of inflammation.

The gall-bladder contains bile, and is usually healthy, though its walls
are sometimes thickened. The larger bile ducts appear normal. It is
remarkable that, inasmuch as there is cholangitis, bilirubin-calcium calculi
are not more often present in the ducts. Gall-stones have been found in
cases of hypertrophic biliary cirrhosis, and can be quite well explained
as a secondary formation; it is not necessary to assume that they are
primary and the cause of the cirrhosis.

Microscopically the liver shows monolobular cirrhosis ; connective tissue
of a delicate and open structure, fibrillar rather than fibrous, separating the
individual lobules from each other. This fibrosis in parts invades the
lobules, and then becomes pericellular ; so that as compared with common
cirrhosis, the fibrosis is less dense, but is more intimately related to the
liver-cells. In addition, there is in most cases ordinary multilobular cirrhosis.
Yery probably this is a secondary lesion, and may, as Chauffard has suggested,
be due to poisons manufactured in the spleen and conveyed to the liver by
the portal vein.

The small bile ducts show proliferation of their epithelium, which may
block up their lumen (cholangitis), so that instead of being lined by a single
layer of columnar cells, the ducts may contain smaller proliferated cells.
In places there is an increased amount of fibrous tissue around the ducts,
due to pericholangitis. The bile capillaries may contain plugs of inspissated
bile or microscopic calculi. Around the portal spaces there are numbers of
the so-called new bile ducts, rows of small deeply staining cells. A good
deal of discussion has taken place as to their nature and origin ; they
are met with in very diverse conditions, i.e. common cirrhosis, acute yellow
atrophy, and gumma. Various interpretations have been put upon this ap-
pearance. They have been thought to be new bile ducts, old bile ducts that
from recession of the surrounding parts have become unduly prominent,
degenerating and compressed liver -cells, or the result of compensatory
hyperplasia of the liver-cells. They may, perhaps, more conveniently be
called " pseudo-bile canaliculi." Though once regarded as connected with
biliary cirrhosis no such importance can now be attached to them, inasmuch
as they are met with in such various conditions, and are sometimes absent
in hypertrophic biliary cirrhosis.

The liver-cells are often extremely well preserved, and commonly do
not show the fatty and atrophic changes met with in ordinary cirrhosis.
They may show signs of karyokinesis. Hanot laid stress on the absence of
degeneration in the liver-cells ; but this must not be pressed too far, for
acute degeneration changes leading to icterus gravis may supervene and
rapidly prove fatal. It appears that Hanot's early observations were
largely based on examination of a case that succumbed from pneumonia,
and did not run the ordinary course of the disease.

The spleen is also much enlarged, it may indeed, exceptionally in
children, be bigger than the liver. Its weight is usually between 15 and 40
oz. It shows peritoneal adhesions, and on section is firmer than normal,
and microscopically presents lymphatic hyperplasia and fibrosis.

The lymphatic glands in the portal fissure are sometimes enlarged, but
are so soft that they do not exert pressure on the bile ducts. They are

LIVER, DISEASES OF 499

dark in colour and oedeniatous; microscopically there is fibrosis and
pigmentation. Besides those in the hilum of the liver the glands around
the pancreas may be similarly affected. In some exceptional instances
glandular enlargement has been detected in distant parts of the body, in
the axilla, the groin, the mediastinum, and the neck (Popoff).

The alimentary canal is usually free from signs of past inflammation.
Hanot noted that the duodenum in the region of the biliary papilla was
not affected by catarrh; Debove's experience, however, is rather in the
opposite direction.

The pancreas is not increased in size, but shows a very intimate
embryonic fibrosis spreading from the ducts, and thus resembling the
changes described in the liver.

All the organs are bile-stained.

Symptoms. — The onset may be gradual, and before jaundice sets in
malaise, loss of strength, and in some cases dyspepsia may be
noticed.

Jaundice is slight at first, and becomes more marked as the disease
progresses ; it is permanent, but varies in degree, being intensified at
intervals when exacerbations in the disease occur. After these crises it
recedes, and eventually it may become green.

The abdomen enlarges from the increase in size of the liver and spleen,
and there is dull pain and tenderness in the hepatic region. It is note-
worthy that there is no enlargement of the subcutaneous veins on the
abdominal wall.

The tongue is furred, the appetite is sometimes poor, but in other cases
is good ; there is said not to be any distaste for fatty food as there often is
in obstructive jaundice. Exceptionally the appetite is ravenous. Nausea
and vomiting may occur, but are by no means constant. Diarrhoea is often
present. The motions contain bile ; this is a point of distinction between
the disease and obstructive jaundice with hepatic enlargement.

From time to time attacks of abdominal pain with fever and increase in
the degree of jaundice occur ; these exacerbations are like those seen in
pernicious anaemia and in Addison's disease. Occasionally acute degenera-
tive changes in the liver-cells occur in one of those attacks, with the result
that the jaundice becomes deep ; delirium, nervous symptoms, and a typhoid
condition develop, and death follows.

The jaundiced skin may become very dark in colour, even resembling
melanodermia ; it may also be very irritable, and become covered with an
eczematous or lichenous eruption. The long-continued jaundice may lead to
xanthelasma.

When the disease occurs in childhood, growth is naturally interfered
with, and the appearance may be infantile, and bodily development greatly
retarded, so that the onset of puberty is arrested. In some rare in-
stances clubbing of the fingers and toes with deformities of the nails
have been noticed. Examination with X-rays has shown that there
is no bony enlargement of the terminal phalanges. In their spleno-
megalic type of biliary cirrhosis occurring in children, Gilbert and Fournier
have further recorded enlargements of the ends of the long bones,
pain in the joints, and synovial effusion. These lesions, which resemble
Marie's hypertrophic pulmonary osteo-arthropathy, are extremely rare in
biliary cirrhosis, and are not dependent on pulmonary lesions. They are
not limited to this form of jaundice, for they were marked in a case in St.
George's Hospital under the care of Dr. Ewart, in which a gumma
obstructed the bile ducts of a boy aged seventeen years. The bulbous or

500 LIVEB, DISEASES OF

" Hippocratic " fingers have been found associated with perforating ulcer of
the foot and neuritis in hypertrophic biliary cirrhosis.

The blood may show leucocytosis, thus differing from common cirrhosis
where it is not found.

It was found in three cases by Hanot and Meunier where there was no cause
for it, such as inflammation elsewhere, and they quote two other cases, making
five in all. Kirikow, however, finds that leucocytosis is not constant.

The heart tends to dilate, and its contractions are somewhat feeble, but
its rate is not slowed.

Epistaxis and h£emorrhages from the gums and in the skin are frequent
in the later stages, but the copious hgematemesis met with in common
cirrhosis rarely occurs.

The urine is acid, diminished in quantity and high-coloured, but not
prone to lithatic deposit as in common cirrhosis. Albumin and sugar are
absent ; owing to the liver-cells being preserved, at any rate for a consider-
able time, in good nutrition, glycosuria cannot be produced by giving syrup
or sugarly food by the mouth. (Absence of alimentary glycosuria.) Urea
is diminished in amount. Bile pigment is practically always present in the
urine. The toxicity of the urine is feeble, and this has been used as an
argument against the view that hypertrophic biliary cirrhosis is primarily
due to a general hsemic infection.

Physical Signs. — The liver is much enlarged, and smooth, and firm to
the touch ; occasionally it is slightly irregular from the presence of peri-
hepatitic adhesions. It is uniformly increased in size. Its dulness often
extends upwards to the fourth rib in the right nipple line, and downwards
to the umbilicus, or even below that point. The pressure of the enlarged
organ pushes the costal arch out. On palpation there is general but not
any localised tenderness. There is no enlargement of the gall-bladder.
The enlargement of the liver is, generally speaking, progressive ; it may
vary from time to time, and late in the disease may sometimes diminish in
bulk from some degree of contraction of the fibrous tissue, probably from
secondary multilobular cirrhosis.

The spleen is very considerably enlarged, much more so than in common
cirrhosis. The enlargement is more marked in children in accordance with
the fact that its capsule is more distensible than in adults. A special form
of hypertrophic biliary cirrhosis has been described by Gilbert and Fournier
as the juvenile type or cirrhose biliare splenomegalique. The spleen may
indeed be not only relatively but absolutely heavier than the liver.
Auscultation over the spleen sometimes reveals a soft blowing murmur.

Three forms of the disease have been described : (i.) the common one, in
which both organs are much enlarged; (ii.) a form in which the liver is
chiefly prominent; and (iii.) the one where the splenic enlargement is
especially marked.

The splenic enlargement may precede the hepatic, and may occur in some
members of a family in which others have the fully developed disease.
Thus in a family recorded by Boinet the father and two children had
hypertrophic biliary cirrhosis, while three other children had enlarged
spleens.

There is no enlargement of the subcutaneous veins of the abdomen, and
ascites is not present except in the last stages, and then usually only in a
slight degree.

At first and for a considerable time the general health is often well
preserved. After repeated exacerbations the condition advances, and as
wasting sets in the patient goes down hill.

LIVER, DISEASES OF 501

Deatli may occur from intercurrent disease, from icterus gravis, or
gradually in coma. Fatal hasmatemesis is very rare indeed.

Diagnosis. — In cases of common cirrhosis with big livers and inter-
current jaundice the diagnosis depends on the jaundice being transitory and
not permanent, on the slight degree of splenic enlargement, and on the
presence of signs of common cirrhosis such as ascites and enlargement of
the subcutaneous veins of the abdomen. It cannot, however, be maintained
that the two diseases (portal and biliary cirrhosis) are always distinct either
anatomically or clinically. Sometimes they are combined, and not in-
frequently the diseases overlap in the same way as the parenchymatous
and interstitial forms of nephritis.

In hemochromatosis, a condition where there is widespread pigmenta-
tion of the body with secondary cirrhosis of the liver and pancreas, the
liver is enlarged, and many of the symptoms resemble those of hypertrophic
biliary cirrhosis. The skin, however, though pigmented is not jaundiced,
and in five-sixths of the cases there is glycosuria (bronzed diabetes).

In cases of obstructive jaundice the liver may be enlarged and swollen
from retained bile ; but this condition differs from hypertrophic biliary
cirrhosis in the absence of bile from the fasces, in the fact that there is no
splenic enlargement, and often in the presence of an enlarged gall-bladder.

When a gall-stone lies in the common duct and gives rise to chronic
jaundice, some bile often passes by the stone and enters the duodenum, so
that the fasces are not necessarily pale. The spleen, however, is not en-
larged; this and the history of severe attacks of biliary colic should
differentiate it from hypertrophic biliary cirrhosis.

In prolonged catarrhal jaundice the spleen is but slightly enlarged, and
bile is absent from the fasces.

In prolonged cases of what appear to be infectious jaundice the condition
is indistinguishable from that of hypertrophic biliary cirrhosis, except in the
fact that recovery occurs; in other words, the diseases are practically
identical in nature though not in their results.

In Weil's disease the clinical course is rapid and acute, whereas hi
hypertrophic biliary cirrhosis it is a matter of years, not of days.

Malaria, which has been regarded by Lancereaux as the cause of hyper-
trophic biliary cirrhosis, can be eliminated by examination of the blood and
by the failure of quinine to affect the course of the disease.

Some rather exceptional cases of syphilitic disease of the liver, with
chronic jaundice and very considerable enlargement of the liver and spleen,
may imitate hypertrophic biliary cirrhosis. Syphilitic lesions elsewhere,
albuminuria as pointing to lardaceous disease as the cause of splenic en-
largement, irregularity of the surface of the liver from gummata, the
presence of enlarged veins on the abdomen, and the beneficial effects of
antisyphilitic treatment, point to syphilis. Another point is the absence
of leucocytosis in syphilis and its presence in hypertrophic biliary cirrhosis.

Teeatment. — In the early stages an attempt may be made to put the
patient in more healthy surroundings, and to remove him from the condi-
tions, among which the water-supply may play a part, that favoured the
onset of the disease.

The patient should avoid cold, especially damp cold, and should be
warmly clad. A course at Carlsbad, Vichy, Marienbad, or Kissingen may
be tried.

It is most important that the diet should be of a simple character and
free from spices or irritating constituents. Milk is the staple, and is
specially advantageous from its diuretic effect on the kidneys. To this eggs

502 LIVEE, DISEASES OF

and bread and butter with occasionally fish may be added. Alcohol should
be avoided as far as possible.

Intestinal antiseptics, such as calomel, /2-naphthol, salol, and so forth,
should be given. The first named is said to give good results ; it is also
useful in preventing constipation and auto-intoxication from stagnation of
fsecal matter.

Duration and Prognosis. — Though the disease is probably incurable
it is often prolonged for many years, jaundice lasting for ten or more years.
The average duration of symptoms is about five years. The symptoms may
recede on careful treatment, but alcoholism, exposure, or over-work will
bring them back.

In some few recorded cases the disease has run a very acute course.

Clubbing of the fingers, though a rare condition, is only met with in
long-standing cases, and is an indication that the course of the disease is
slow.

LITERATURE. — Adami. Sajou's Annual, article "Cirrhosis," 1898. — Boinet. Archiv.
ghidrales de midccine, April 1898. — Charcot et Gombault. Archiv. de Physiologic, 1876. —
Dreschfeld. Medical Chronicle, April 1896. — Gilbert et Fournier. Soc. de biolog. Paris,
March 26, 1898.— Hanot. These de Paris, 1876.— Harley, V., and Barrett. Brit. Med.
Journal, 1898, vol. ii. p. 1743. (For experimental ligature of bile ducts.) — Hawkins. Allbutt's
System of Medecine, vol. iv. — Hayem. Archiv. de Physiologie, 1874. — Legg, W. St. Bartholo-
mew's Hospital Reports, 1873. — Todd. Medical Times and Gaz. 1857, p. 871.

Obstructive Biliary Cirrhosis

By obstructive biliary cirrhosis is meant a fibrosis spreading from the
bile ducts around the lobules of the liver, and due to obstruction of the
large bile ducts. Charcot and Gombault, who described this condition,
supported their contention by the results of ligaturing the common duct
in animals, an experiment that Wickham Legg had previously performed
in this country. In these experiments the ducts were found to be dilated,
and to be the starting-point of fibrosis which surrounded the individual
lobules and sometimes penetrated into their substance ; in the fibrous tissue
surrounding the hepatic lobules there were numerous new bile ducts
(pseudo-bile canaliculi) which joined on to the liver-cells. These experi-
ments have been frequently repeated, and the conclusion to be drawn from
them is that the cirrhosis obtained by the earlier workers was due to infec-
tion, and that aseptic ligature of the ducts leads to little or no fibrosis, but
merely to focal necrosis of the liver-cells. The facts observed in the human
subject are in general agreement with the foregoing. When the common
bile duct is compressed by malignant disease, for example in carcinoma of
the head of the pancreas, the bile ducts become dilated, and there are de-
generative and necrotic changes in the liver-cells, but practically no fibrosis.
On the other hand, when a gall-stone is lodged in the common bile duct
the results are not so constant ; sometimes the changes are the same as in
aseptic closure of the common ducts ; but in other instances there is
cholangitis and pericholangitis, which if the process is chronic results in
fibrosis around the ducts. The determining factor is evidently in great
measure the freedom from or presence of an ascending infection of the
ducts. The histological changes thus produced are not the same as those
of hypertrophic biliary cirrhosis {vide p. 498).

It must, however, be remembered that obstruction of the bile ducts
necessarily carries with it the absence of bile in the intestines ; the latter
is a factor that will tend to increase fermentation in the alimentary canal,
and so lead to the production of poisons, which when carried to the liver

LIVEE, DISEASES OF 503

might be expected to set up the ordinary portal or multilobular cirrhosis.
This change would indeed in all probability more often be met with, were
it not that the liver, being flooded with bile, which has acquired toxic
properties as shown by the focal necrosis of» the liver-cells, is incapable of
any reaction.

Cases of long-standing gall-stone obstruction associated with ordinary
portal cirrhosis of the liver undoubtedly occur ; but the symptoms are chiefly
those of biliary obstruction, and not of portal vein obstruction.

Hypertrophic biliary cirrhosis has sometimes been found associated
with gall-stones, but it is quite reasonable to think that the gall-stones are
secondary to cholangitis, and not the primary morbid factor.

Clinical Features. — When cirrhosis of the liver, whether it be peri-
cholangitic or portal, occurs in a patient with biliary obstruction, it does
not give rise to any special signs or symptoms. The features remain those
of biliary obstruction.

In some instances a gall-stone may become lodged in the common bile
duct without any history of colic being obtained. In such cases the
question of diagnosis may be one of considerable difficulty {vide p. 501).
As time progresses bile may escape by the side of the stone into the
duodenum, and the faeces are no longer pale ; they then contain bile just as
they do in hypertrophic biliary cirrhosis.

In differentiating these two conditions the size of the spleen is im-
portant; big in hypertrophic biliary cirrhosis, not enlarged in gall-stone
obstruction. In hypertrophic biliary cirrhosis the liver is greatly increased
in size, in biliary obstruction it is swollen from retention of bile, but in the
late stages and when fibrosis develops it becomes smaller.

To sum up : A chronic ascending cholangitis leading to pericholangitic
fibrosis may be associated with and favoured by gall-stone obstruction, but
it depends on infection, and not on obstruction of the ducts per se. This
fibrosis is clinically of little importance, the features of the case are those
of obstructive jaundice.

In some instances ordinary portal cirrhosis may develop after gall-stone
obstruction has been established, and is reasonably explained as the result
of poisons manufactured in the intestines and carried to the liver by the
portal vein.

Complete aseptic obstruction of the common bile duct leads to dilatation
of the intra-hepatic ducts and to focal necrosis of the liver-cells, but not to
cirrhosis. The functional activity of the liver is thus very gravely inter-
fered with, and as a result of this hepatic inadequacy cholaemia or biliary
toxaemia results, a condition which is much more rapidly fatal than
cirrhosis.

Finally, biliary obstruction does not give rise to any fixed type, either
pathological or clinical, of cirrhosis.

LITERATURE. — Charcot and Gombault. Archiv. de physiolog. normal et path. 1876,
p. 272. — Barley and Barrett. Brit. Med. Journ. 1898, vol. ii. p. 1743. — Legg, Wickham.
St. Bart.' s Hosp. Reports, 1873. — Sharkey. St. Thomas' Hosp. Reports, vol. xviii. p. 245. —
Weber, F. P. Brit. Med. Journ. 1896, vol. i. — Janowsky. Ziegler's Beitrcige, Bd. xi.
S. 344.

Portal Cirrhosis

Introduction . . . . 504

Etiology ..... 504

Alcohol .... 504

G astro-intestinal Catarrh . 504

Micro-organisms . . . 505

Sex. Age .... 505

504

LIVEE, DISEASES OF

Morbid Anatomy

. 505

Symptoms .

Associated Lesions —

Hcamatemesis

Tuberculosis

. . .510

Complications .

Renal Disease

. 510

Diagnosis .

Course

. 511

Prognosis .

Signs of Cirrhosis

. 511

Treatment

Ascites

. 512

515
515
516
517

518
518

Synonyms. — Common, Atrophic, or Multilobular Cirrhosis; Hobnailed Liver;
Gin or Whisky Drinker's Liver ; Chronic Interstitial Hepatitis.

Introduction. — The term cirrhosis was first employed by Laennec
(1819), who regarded the yellow bile-stained "hobnails" as due to some
new formation, and therefore termed it cirrhosis (/appos = yellow). The
term atrophic cirrhosis, though in common use, is undesirable, inasmuch as
many of the livers of multilobular cirrhosis are by no means small. The
adjectives portal, multilobular, or common are more suitable.

Etiology. — The changes of cirrhosis are due to the action of poisons or
possibly poison-producing bodies — micro-organisms — reaching the liver.

These bodies are usually conveyed to the liver by the portal vein, but
in some instances they reach the liver by the hepatic artery. Thus in the
rare condition hemochromatosis, where there is widespread infiltration of
the body with blood pigments set free by haemolysis, possibly of microbic
origin, the liver and pancreas become fibrotic. The hepatic artery in these
cases shows endarteritis. Again, in scarlet fever there may be an acute
interstitial hepatitis analogous to acute nephritis, and, like it, due to a
poison reaching the liver from the general circulation ; it is possible that
traces of this lesion may persist and lay the foundation of ordinary
cirrhosis. The same may be true of other specific fevers such as measles.
Similarly, in the haemic infections it is not improbable that focal necrosis of
the liver-cells and connective tissue proliferation around these areas may
under certain conditions lead to cirrhosis.

In most instances, however, cirrhosis appears to be due to poisons
reaching the liver by the portal vein. Alcohol has always been considered
the cause par excellence of hepatic cirrhosis, and figures largely in the past
history of patients. It is not, however, the typical drunkard so much as
the constant tippler who develops cirrhosis. Experimentally alcohol gives
rise to degeneration and fatty changes in the liver-cells and not to cirrhosis,
so that it would appear that alcoholism only produces cirrhosis indirectly
by favouring the development of the necessary factors.

It has been suggested that though alcohol itself does not lead to
cirrhosis, alcoholic liquors, in virtue of other constituents, such as sulphate
of potash (Lancereaux), with which wines are " plastered," amyl alcohol, or
fatty acids, have this effect.

A very probable view is that alcoholism gives rise on the one hand to
gastro-intestinal catarrh, and thus to the formation of poisonous bodies,
which are the active factors in the production of cirrhosis, and that, on the
other hand, it acts as a protoplasmic poison, and reduces the resistance of
the liver, thus allowing the aforesaid poisons to act more vigorously and at
greater advantage.

Cirrhosis may undoubtedly occur without alcoholism, and recently
Hanot and Boix have described dyspeptic or " Budd's cirrhosis," probably
brought about by fatty acids, such as acetic, butyric, valerianic, and lactic,
manufactured in the alimentary canal as the result of fermentation. In this
way cirrhosis may be set up by spices and other articles of stimulating diet.

LIVER, DISEASES OF 505

In some instances, as Chauffard has suggested, poisons may be manu-
factured in the spleen and be carried to the liver by the portal vein, and
then set up cirrhosis. Thus in Banti's disease, a severe form of splenic
anaemia with terminal cirrhosis, it is probable that a chronic intoxication
or infection chiefly affecting the spleen leads to this further change in the
liver.

The role of micro-organisms in the production of cirrhosis, though
rendered highly 'probable by the suggestive work of Adami and his pupils,
is not at present satisfactorily established. It would appear probable that,
as the result of alcoholism, the walls of the intestines may be so damaged
as to allow of their penetration by micro-organisms, which thus reach the
liver, and if its resistance is also diminished by the toxic effects of alcohol
they may multiply, and by their toxins induce cirrhosis. A small diplo-
coccus belonging to the colon group has been found by Adami, not only in
cirrhotic, but also in other and even in normal livers. It was suggested that
while in health the micro-organisms are destroyed by the liver ; in patho-
logical conditions, where the resistance of the liver is reduced, the micro-
organisms may become virulent, and lead to the changes of cirrhosis.

Syphilis does not give rise to ordinary portal cirrhosis. The hepatic
lesion of congenital syphilis is a diffuse pericellular infiltration, which is a
curable condition. As pointed out elsewhere (vide p. 545), patients who
have presumably had this lesion may, their liver being a place of least
resistance, develop ordinary multilobular cirrhosis on slight provocation ;
this may be regarded as a parasyphilitic lesion.

Malaria is often mentioned as a cause of cirrhosis, but there is reason to
believe that the two diseases are rather associated together than related as
cause and effect. Though malaria induces changes, necrosis and hyperplasia
of the liver-cells, which might cause cirrhosis, this is not very frequently
proved actually to occur in practice.

Incidence. — Males are more often affected than females in the proportion
of 5 J to 2 ; in 508 cases of cirrhosis, obtained by adding together the
statistics of Price, Kelynack, Yeld, Fenton's and my own, 374 were males
and 134 females. It appears, however, that the disease is more often latent
in men than in women. In children also the male sex is more often
attacked than the female.

Age. — The average age at which cirrhosis is fatal in adults is about
forty-eight years ; if the examples of cirrhosis in young children are
included the age would of course be lower. A large proportion of the cases
fatal in children occur before six years of age.

Morbid Anatomy. — The size and weight of the liver in portal cirrhosis
vary considerably. Sometimes the liver is much reduced in size, and may
weigh under 30 oz. ; in other cases it is as much as twice the normal
weight. As a rule it is rather heavier than natural. In 114 cases at St.
George's Hospital the average weight was 65 oz., in 100 cases collected by
Hawkins the average was 52 oz., and in 93 collected by Kelynack 53 oz.
It is noteworthy that a cirrhotic liver which looks considerably smaller
than a normal one often weighs as much or more, its specific gravity being
increased.

Various forms of portal cirrhosis have been described, and different
causes are assigned for the large cirrhotic livers. In some cases the
increased size is due to fatty change in the liver-cells, and it has been
assumed, but probably incorrectly, that this is especially associated with
indulgence in malt liquors. When cirrhosis is associated with pulmonary
tuberculosis the liver is often enlarged and fatty. In some instances the

506 LIVEE, DISEASES OF

increase in size is due to compensatory hyperplasia of the liver-cells — the
hypertrophic alcoholic cirrhosis of Hanot and Gilbert — and is associated
with latency of the symptoms and arrest of the disease. In other instances
the large size is due to the fibrosis having a smaller mesh and approaching
a monolobular type ; these cases may appropriately be described as mixed
cirrhosis. Generally speaking, the liver is larger in young subjects with
cirrhosis than in cases fatal later in life. The larger cirrhotic livers are
less knobby than the small cirrhotic livers, which especially merit the term
" hobnail."

The capsule is more opaque than in health, but there is very seldom
much chronic perihepatitis. There may be adhesions between the surface
of the liver and the diaphragm ; when present they are scattered rather
than extensive, and are usually markedly vascular.

The surface of the organ is irregular, the projections vary in size from a
pea to that of a pigeon's egg. When they are small the surface somewhat
resembles that of a granular kidney, and the term " granular liver " is
applicable. When, as more rarely occurs, the hobnails are large, the organ
may look as if it was occupied by numerous secondary growths, especially
when the projections show marked fatty change and appear white, though it
is worthy of note that the hobnails are never umbilicated, as is usual in
secondary carcinoma. When the projections are exceptionally large the
condition is sometimes spoken of as nodular cirrhosis, or cirrhosis with
multiple adenoma (vide p. 528). The hobnails are of a tawny yellow or
brown colour, being often stained by bile ; the peritoneum over them
sometimes shows dilated vessels. During life the liver looked uniformly
red in the laparotomies in cases of cirrhosis I have seen. The capsule,
which is not much thickened as a rule, is more opaque in the depressions
between the nodules.

Usually the liver is uniformly affected, especially when it is enlarged
and the nodules are small, but the change may be irregular, and the left
lobe is often in a more advanced condition, and may be very small. It is
possible that the resistance of the left lobe is less than that of the right, for
it is not infrequently more affected in acute yellow atrophy (q.v.) than the
right. Sometimes, on the other hand, one of the smaller lobes, such as the
Spigelian or caudate lobe, may be enlarged out of proportion to the others,
even when the organ as a whole is little if at all bigger than normal.

On section the liver is much tougher than normal, and is like a section
of conglomerate stone being divided up into areas of irregular size by gray,
slightly gelatinous-looking fibrous tissue. This fibrous tissue is continuous
with the depressed, more opaque areas on the capsule, and by its contraction
has squeezed into prominence the more healthy parts of the liver, which
thus form the nodules or hobnails. This fibrosis spreads out from the
medium-sized portal canals, and exerts its constricting influence on the
branches of the portal vein. The areas of liver substance thus enclosed
vary in size, usually being from \ to \ inch in diameter, and enclose six to
ten lobules, each of which normally measures about tV-^tt mcn m diameter.
The liver substance is much paler than in health, and has a yellowish
brown colour from staining with bile. In exceptional cases there may be
haemorrhage either into the hobnails or into the surrounding interstitial
tissue ; in the latter event, if there is fatty degeneration in the hobnails,
the resemblance to new growth may be very realistic. In some cases the
hobnails soften down in the centre.

Histology. — In the early or more progressive stages there is small-cell
infiltration in and around the portal spaces ; these cells are due to hyper-

LIVER, DISEASES OF 507

plasia of the existing connective tissues of Glisson's capsule ; some
leucocytes are also present. In a well-marked case there is an irregular
mesh-work of fibrous tissue extending throughout the liver, and dividing it
up into variously sized islands of liver tissue. Inasmuch as a number of
lobules are enclosed within the same fence of fibrous tissue the term multi-
lobular cirrhosis is applied. The number of lobules enclosed in different
compartments differs ; in some parts there are many, in other areas a single
lobule or half a lobule is separated off from the rest.

The French school considers that the fibrosis is not only portal, but also
around the sublobular veins, or bivenous. It is true that the pressure of
the surrounding fibrous trabecular may obliterate the intra-lobular veins, and
in other ways so alter the appearance of the lobule that it is difficult to
count the number of lobules enclosed in the alveoli of the fibrous tissue, but
it does not appear, at any rate to me, that there is fibrosis around the intra-
lobular veins. At the margin of the lobules the fibrous tissue can be seen
to surround bits of the lobule, and thus to shave off groups of cells from the
edge of the lobule. In some large cirrhotic livers, where the mesh- work is
still multilobular as a whole, there are parts where it is more diffuse and
approaches the monolobular type; this condition of mixed cirrhosis is a
transitional stage to biliary cirrhosis. The fibrous tissue varies according
to the age and rate at which the process is progressing. Usually there
is some well-formed fibrous tissue containing younger connective tissue
and small round cells. The interstitial fibro-nuclear tissue contains
numerous small vessels with thin walls derived from the branches of the
hepatic artery. Elastic fibres are present in the fibrous tissue.

In addition the fibrous tissue contains columns of small cells with
deeply-staining nuclei, often described as new bile ducts. This appearance
is seen in many conditions, such as gumma, tubercle, lymphadenoma, and
acute yellow atrophy, where destruction of the liver-cells is occurring.
They have been regarded in the following various lights, as degraded liver-
cells reverting to the type of bile ducts, as normal bile ducts which have
become exposed by atrophy and recession of the liver-cells, and as a
hyperplasia of the liver-cells — an attempt to compensate for the destruc-
tion of liver-cells. The latter seems a satisfactory explanation, and this
appearance may therefore be spoken of as " pseudo-bile canaliculi."

In some cases of malarial cirrhosis, in the liver of hemochromatosis, and
in the rare condition of cirrhosis anthracotica, the fibrous tissue may
contain opaque masses of pigment.

The normal arrangement of the liver-cells in the lobule is lost, probably
from the pressure exerted by the contracting fibrous tissue. The cells show
degenerative changes, atrophy and fatty change are common, while pig-
mentary infiltration may occur.

Several views have been put forward as to the relation of the fibrous
tissue formation to the degenerative changes in the liver-cells ; it has been
thought that the fibrous tissue is first formed by active proliferation, and
that by its subsequent contraction, atrophy and degeneration of the liver-
cells are induced, while conversely it has been held that the degeneration
of the liver-cells is primary and that the fibrosis is only apparent, or at
best a replacement fibrosis, and the process comparable to that in a granular
arterio-sclerotic kidney. Probably the two changes are both due to toxic
causes and independent of each other at first, later fibrous contraction may
increase the atrophy of the liver-cells, while in return the products of
degeneration of the cells may further stimulate hyperplasia of the con-
nective tissue elements.

508 LIVER, DISEASES OF

The large tile ducts and the gall-bladder are usually healthy to the
naked eye. The walls of the gall-bladder are, however, sometimes rather
thickened and contracted.

Biliary calculi are not specially frequent in cirrhosis ; in 100 cases of
fatal cirrhosis examined at St. George's Hospital 12 showed calculi either
in the gall-bladder or the small ducts, the later being bilirubin-calcium
calculi.

The hepatic artery is usually enlarged inasmuch as it supplies the
added fibrous tissue in the organ. In the multilobular cirrhosis of hsenio-
chromatosis the artery shows endarteritis.

Portal Vein. — The intra-hepatic branches are compressed while the
trunk is accordingly somewhat dilated. Its walls show some thickening,
and its intima is rather opaque. The communications between the radicles
of the portal vein and the general systemic veins are greatly enlarged
and increased in extent. Thrombosis of the portal vein occasionally occurs
in cirrhosis. Cirrhosis of the liver, indeed, is the most frequent associated
condition of pyle-thrombosis, but it is not a common occurrence.

Communications betiveen the Portal System and the General Systemic
Veins. — The anastomoses which normally exist between the radicles of the
portal vein and the adjacent systemic veins become dilated and increased
in extent in common cirrhosis. The portal circulation is thus short-
circuited, and the engorgement relieved by the passage of some of the blood
into the inferior or superior vena cava without traversing the liver. The
development of this collateral circulation relieves portal congestion, and is
thought to be compensatory.

These communications are —

1. A general anastomosis between the veins of the peritoneum and
those of the abdominal walls, such as the lumbar and renal. These
anastomoses are especially well marked where the duodenum and colon
are bound down to the abdominal wall and are only partially covered by
peritoneum. This subperitoneal anastomosis, described by Eetzius, gives
rise to marked injection of the peritoneum, which is especially noticeable
during life, as seen in laparotomies on cases of cirrhosis.

2. Those around or in connection with the liver. The phrenic and
intercostal veins on the diaphragm communicate between the layers of the
coronary ligament with the veins in the liver ; this is not of much utility.
Dendritic venous markings on the skin along the line of attachment of the
diaphragm occur in conditions like emphysema, and have no constant
relation to cirrhosis. In the falciform ligament the parumbilical veins of
Sappey put the portal vein into communication with the veins of the
anterior abdominal wall. A large vein may thus run up in the falciform
ligament which imitates the anterior epigastric vein of the frog. This
anastomosis may show itself as a " caput medusas," or number of dilated
veins around the umbilicus. This anastomosis must be distinguished from
the more marked " caput medusa? " which results from obstruction to the
passage of blood along the inferior vena cava ; in the latter the dilated
epigastric and mammary veins avoid and do not centre around the
umbilicus. In cases of extensive ascites both collateral circulatory
channels may be developed.

An epigastric venous hum, audible with the stethoscope, has been
referred to the collateral circulation in the falciform ligament.

3. Between the oesophageal veins, discharging into the azygos veins and
so into the superior vena cava on the one hand, and the gastric veins on the
other hand. These veins may become varicose (oesophageal piles), and as the

LIVEE, DISEASES OF 509

result of chronic inflammation the mucous membrane may become first
adherent and then ulcerated. Profuse and even fatal haematemesis may
thus be induced. In 80 per cent of the cases of fatal gastro-intestinal
haemorrhage these oesophageal varices are present. Varicose gastric veins,
especially around the cardiac orifice, are present in a small proportion of
cases.

4. Between the superior hemorrhoidal veins, tributaries of the inferior
mesenteric vein, and the middle and inferior hemorrhoidal veins which
open into the internal iliac veins. Dilatation and varicosity of these veins
lead to piles. It is probable that cirrhosis is not so important a cause of
piles as has sometimes been stated, and at any rate takes a very subordinate
position in this respect to constipation.

This collateral circulation is regarded as compensatory, but it often fails
in this object, as shown by its presence in fatal cases, while it is sometimes
absent in cases where latent cirrhosis is found in persons dying from other
causes. Its good effects have been imitated in the recent treatment of cir-
rhosis by the production of artificial adhesions. If carried to its logical conclu-
sion this measure would result in short-circuiting the portal circulation as in
Eck's fistula, or the union of the portal vein with the inferior vena cava —
an experiment that induces a uremic tendency in dogs. It is probable that
the good effects of the operation are not due to relieving portal congestion
alone, but to improve nutrition of the liver, promoting hyperplasia of
its cells.

The Spleen. — Enlargement of the spleen is an important and very
frequent feature of cirrhosis ; it is present in 80 per cent of the cases. It
does not, however, appear to be enlarged in cases where cirrhosis, though
present, is latent. It is enlarged early in the course of the disease, and may
diminish in size as the result of haemorrhage, severe diarrhoea, or ascites.
The enlargement does not bear any relation to the size of the liver in
ordinary cirrhosis, though in biliary cirrhosis there is a certain relation
between the large liver and the spleen.

The splenic enlargement was formerly thought to be mechanical, and
due to congestion depending on portal obstruction ; that this is not the
exclusive factor is shown by the following facts : —

(i.) That the enlargement is an early sign before evidence of portal
obstruction has become apparent.

(ii.) That in biliary cirrhosis, where portal obstruction is slight or at
any rate much less marked than in common cirrhosis, the splenic enlarge-
ment is much more marked.

(iii.) That the average weight of the spleen in 56 cases of morbus cordis,
uncomplicated by any febrile or toxic process, was 7"3 oz., while in 84 cases
of cirrhosis the spleen averaged 12-9 oz. (Kelynack). It is true, however,
as Foxwell has pointed out, the liver acts as a kind of buffer in cases of
morbus cordis, and the passive congestion of the spleen need, therefore, not
be so great as in cirrhosis where the obstruction is in the portal circulation.

On the other hand,, passive congestion plays some part in the splenic
enlargement, for haemorrhages may lead to considerable diminution in the
size of the organ in cirrhosis, and thrombosis of the splenic vein may be
followed by very great splenic enlargement.

No doubt the important factor in the splenic enlargement in cirrhosis
is toxic rather than purely mechanical. The poisons reaching the organ by
the splenic artery give rise to an inflammatory swelling ; but when there
is passive congestion superadded the enlargement will be accentuated.

A certain amount of chronic inflammation of the capsule or perisplenitis

510 LIVEB, DISEASES OE

is common ; it may be localised in the form of corneal or lamellar fibromata,
or generalised as in chronic peritonitis. Adhesions to the diaphragm are
not uncommon. In 131 cases of cirrhosis analysed by Yeld there was
chronic perisplenitis in 43, or 33 per cent.

Histologically there is proliferation of the splenic pulp in the earlier
stages of cirrhosis, which may be succeeded later on in the disease by
fibrosis and atrophy like that seen in experimental chronic intoxications.

Peritoneum. — Besides the dilatation of the blood-vessels of the peri-
toneum already referred to there is no constant lesion. A certain degree
of chronic peritonitis is not infrequently seen, and secondary infections may
give rise to acute or tuberculous peritonitis.

The oesophagus shows dilated and varicose veins towards its lower end,
which, as already pointed out, may rupture and give rise to severe or fatal
haemorrhage ; the mucous membrane of the oesophagus may be thickened.

The stomach usually shows chronic gastritis; as evidence of this, pig-
mentation at the pylorus is not uncommon.

The intestines also show signs of catarrh ; when there is chronic peri-
tonitis their length may be considerably curtailed. The pancreas is larger
and heavier than normal, and shows a wide-marked fibrosis with fatty and
pigmentary degeneration of the gland cells.

The heart is commonly flabby, occasionally dilated, and sometimes
shows fatty degeneration, probably from concomitant alcoholism.

The lungs are often oedematous ; the occurrence of tubercle will be
referred to below.

Associated Lesions

Tuberculosis. — The subjects of alcoholic cirrhosis are more prone to
tuberculous infection than non-alcoholic persons dying from other diseases.
This is probably due to alcoholism and not to cirrhosis. Tuberculosis is
most often seen in the lungs and peritoneum ; it may be obsolete, and only
found at the autopsy, or it may be acute, and then throws into the shade
the cirrhosis. Tubercle is found in the bodies of about 30 per cent of
patients with cirrhosis.

Cirrhosis certainly seems to dispose the peritoneum to tuberculous
infection, for its occurrence is comparatively infrequent in adult males
apart from cirrhosis. Probably chronic venous engorgement reduces the
resistance of the peritoneum and its lymphatics.

Kidney Disease. — Adding together the statistics of Pitt, Kelynack,
Yeld, and those of Fenton and myself, 387 cases of cirrhosis are obtained,
among which 87 or 22'5 per cent showed a granular kidney. The arterio-
sclerotic change in the kidney does not complicate the cases of cirrhosis
occurring early in adult life. Statistics show that the average age of
patients with both lesions is higher than those dying with cirrhosis alone.
There does not seem to be any special relation between the size of the liver
a,nd its association with a granular kidney. Price found a granular kidney
more often associated with a large -liver, while Pitt's statistics as well as my
own were exactly opposed to this conclusion. As would naturally be ex-
pected from the greater frequency of arterio-sclerosis in males, the associa-
tion of cirrhosis with the granular kidney is commoner in men than in
women. When the two lesions coexist the symptoms are chiefly those of
renal disease.

Fatty degeneration of the renal epithelium may occur in cases of
cirrhosis, while sometimes the kidneys show the effects of backward pressure
from cardiac failure.

LlVEIi, DISEASES OF 511

The Course of the Disease

The disease may be divided into the early or pre-ascitic stage and the
late or ascitic period.

In the early stage of cirrhosis the symptoms are chiefly those of
dyspepsia, often of an alcoholic nature, with loss of appetite, sickness, and
irregularity of the bowels. Symptoms, indeed, may be absent, or be largely
those of alcoholism.

The pre-ascitic stage begins very vaguely and gradually, but its tenor
may be roughly broken by the occurrence of heematemesis. This may come
on after some discomfort and fever, or may occur with little or no warning.
After it the patient is blanched for a time, but soon recovers, and usually
months or years elapse before ascites develops. In some rare instances the
disease runs a rapid and often febrile course, and almost before the patient
has recovered from the effects of hsematemesis ascites begins to show itself.

After hsematemesis the cirrhotic process may. become latent and give
rise to no further symptoms, especially if the patient alter his habits of life.

The late or ascitic stage may be preceded by gaseous distension of the
abdomen, so that its onset is obscured. CEdema of the feet may precede
the ascites or follow it.

By the time ascites has developed the patient is already pulled down in
strength and weight. The ascites increases in amount, sometimes rapidly,
until tapping is required ; in pure cirrhosis, without any chronic peritonitis,
a second tapping may be required, but rarely more. The ascites then ceases
to accumulate, and may indeed disappear, while the patient further
emaciates, rapidly loses strength, and eventually passes into a drowsy,
typhoid, or comatose condition, which gradually ends in death. The mental
apathy is often varied by delirium of a low type. There may be haemorrhage
from hepatic insufficiency not only into the skin, but from the stomach or
bowel, which may be very considerable.

The patient may linger on in a semi-comatose condition for some weeks
and then die from an acute and terminal infection or from asthenia.

On the other hand, death may occur before the stage of ascites has been
reached, from some complication or acute infective process. Exceptionally,
death may occur from hsematemesis quite early in the course of the disease.

Signs of Cirrhosis

Facial Aspect . . . .511

Liver ..... 512

Venous Hum . . . .512

Ascites ..... 512

Circulatory System . .513

Urine ..... 514
CEdema of Feet . . . 514

Facial Aspect. — The face may be bloated and show acne rosacea due to
dyspepsia, either induced by or independent of alcoholism ; the area of skin
affected is that around the nose and on the cheeks, and roughly corresponds
with that involved in lupus erythematosus, the so-called " flush area." The
skin of the face elsewhere is muddy and dirty-looking, and often presents
stigmata or small clusters of dilated vessels, which sometimes bleed readily
on slight provocation, and capillary haemorrhages. The face is drawn and
thin, the eyes deeply set, and the conjunctiva muddy or slightly icteric.
The wasting of the temporal muscles is often very manifest. These are the
appearances usually seen in the later and more advanced stages.

At an earlier period the skin may be uniformly pale, sallow, and smooth,
and quite free from the blemishes seen in advanced stages.

512 LIVER, DISEASES OF

The lips are usually dry and apt to be fissured, the tongue flabby or
dry, and the gums show a tendency to become spongy and, when hepatic
insufficiency has become established, to bleed. The throat is apt to be
chronically congested and the breath foul.

The skin of the body is often dry and harsh, with loss of elasticity.
Local haemorrhages may occur as the result of slight or unnoticed
traumatism.

The Livee. — It has been widely assumed that the liver is enlarged in
the early stages of the disease, and that subsequently it becomes smaller
from shrinking and contraction of the fibrous tissue inside it. This sequence
of events is sometimes noted; thus the organ a considerable time before
death has been found to be large, while at the post-mortem it has receded
behind the costal arch. At the same time it is by no means certain that
alterations in size of the organ can be referred solely to the contraction of
the added connective tissue ; for, in the early stage, the enlargement may
vary within a comparatively short space of time, thus showing that the
increase in size is due to engorgement.

Before ascites has appeared the liver may usually -be felt below the ribs,
sometimes several finger-breadths beyond the costal margin in the right
nipple line, its surface being firm, slightly irregular, and often tender.

In other instances its rough, hobnailed margin can just be felt by
pushing the fingers under the margin of the ribs, while sometimes it cannot
be felt, and percussion may show that it has apparently diminished in size.

Before the onset of ascites tympanitic distension of the abdomen often
appears, and like ascites prevents accurate palpation of the liver.

Venous Hum. — On rare instances a venous hum, louder on inspiration, can
be caught over the epigastrium, and has been thought to be due to the
presence of dilated vessels in the falciform ligament. In some exceptional
cases a similar venous hum, compared to the uterine souffle, has been heard
over the spleen.

The spleen may sometimes be definitely felt to be enlarged and firm, but
though almost constantly enlarged as shown by examination after death,
tympanites or ascites often mask it during life. Considerable enlargement
may precede hsematemesis, and its detection may therefore be regarded as
a danger signal and call for free purgation.

Ascites. — The onset is gradual; when it is sudden and rapidly accumulates
it may be due to thrombosis of the portal vein. It may come on shortly
after injury, exposure to cold or factors that lower the resistance of the
body, or after inflammation elsewhere in the body. But as a rule no
definite exciting cause is found. It occurs in a large proportion of the
cases dying from cirrhosis, but taking all cases in which cirrhosis of the
liver is found on post-mortem examination, whether fatal from cirrhosis or
from some other disease, the proportion is about 50 per cent.

Ascites is a late event in the course of cirrhosis, and patients seldom
live to be tapped more than twice. When paracentesis has to be performed
frequently in a case regarded as cirrhosis, the condition is either complicated
by chronic peritonitis or the diagnosis is incorrect.

The Causation of Ascites. — The obstruction to the portal circulation
exerted by the cirrhotic liver is hardly sufficient to account for the ascites,
since in experimental ligature of the portal vein ascites is not a necessary
result. Again, it does not occur when presumably the pressure in the
portal vein is highest, namely, at the same time as hsematemesis and melsena.
If the peritoneal effusion depended solely on mechanical obstruction, it
should come on pari passu with cicatricial contraction around the portal

LIVER, DISEASES OF 513

canals in the liver. Further, the rapidity with which the fluid is sometimes
poured out — a pint or more a day — is hardly compatible with the view that
it is solely due to increased venous pressure. It has been suggested that the
onset of ascites may depend on thrombosis of minute branches of the
portal vein, or of its compensatory communications with the general
systemic veins, but of this there is no proof.

The character of the fluid shows that it is not an ordinary acute
inflammatory exudation, and there is nothing to support the hypothesis
that the onset of ascites is due to infection. Chronic peritonitis would
account for the ascites, but this lesion is not a necessary accompaniment of
ascites in cirrhosis.

An attractive theory is that the ascites is toxic and due to the presence
of a poison exerting a lymphagogue action ; this view would explain the
onset of oedema of the feet before ascites, but some further factor is
required to explain the predominance of ascites over oedema elsewhere in
the body. Probably this is to be found in portal congestion; it is easy
to understand that stagnation of venous blood in the portal area would
diminish the resistance of the endothelial cells of the peritoneum, and thus
render them more susceptible to the action of a lymphagogue, while the
large amount of blood at hand would further assist.

Ascitic fluid is usually slightly yellow in colour and clear ; in rare
instances it may be chylous, chyliform, or hemorrhagic. Admixture with
blood seems to be traumatic, and due either to damage done by a previous
tapping, or to rupture of small vessels either in the peritoneum or in
vascular adhesions. When peritonitis is present the fluid becomes turbid
from the presence of pus cells.

The specific gravity is 1008-1015 ; the fluid is alkaline and contains
0-2-0"4 per cent of albumin and occasionally traces of sugar, urea, and uro-
bilin. Bacteriological examination of ascitic fluid has in three cases shown
the presence of Adami's diplococcoid form of the colon bacillus (M. Abbott).

Ascites pushes the diaphragm up, often displacing the heart and leading
to collapse of the bases of the lungs, especially on the right side. For the
physical signs and diagnosis of ascites due to different causes the reader is
referred to special article on "Ascites," vol. i.

The skin of the abdomen shows dilated subcutaneous veins which when
much in evidence are spoken of as caput medusae. The collateral circulation
between the veins of the abdominal wall and the parumbilical veins in the
falciform ligament, centring around the umbilicus, is characteristic of portal
obstruction, and must be distinguished from the dilated superficial epigastric
veins, and the mammary and long thoracic veins, which carry on the
circulation when the flow through the inferior vena cava is interfered with,
and avoid the umbilicus.

In cirrhosis, with ascites, the intra-abdominal pressure may so compress
the inferior vena cava that the collateral circulation through the epigastric
and mammary veins becomes evident, in addition to that due to portal
obstruction.

The abdomen becomes pendulous and flaccid from degeneration and
atony of the muscles in its parietes, and when the ascites is extreme the
umbilicus may become everted and even burst. After tapping, the skin
shows linese albicantes.

Circulatory System. — The pulse is normal in rate, but the tension
is low.

An apical systolic murmur is frequently present, due to dilatation
rather than to valvular disease. Acute dilatation due to alcoholic excess
vol. vi 33

514 LIVER, DISEASES OF

may so alter the aspect of the case that cirrhosis is only revealed at the
autopsy.

When there is ascites the heart may be considerably displaced upwards,
and the apex beat may be in the 3rd interspace. This displacement tends to
produce a slight kink in the pulmonary artery, and thus accounts for a systolic
murmur over the artery which may disappear after paracentesis abdominis.

The Blood. — There is no leucocytosis, and as a rule no special anaemia.
In the late stages the blood becomes toxic, as shown by haemorrhages into
the skin and elsewhere, and by oedema of the feet.

Urine. — The urine is diminished in amount, of high specific gravity, high-
coloured, reddish orange in appearance, and deposits a copious sediment of
lithates. It is highly acid in reaction, and the amount of uric acid is
increased. The amount of urea is diminished, while the ammonia is
increased.

The amount of urobilin is increased, while occasionally urohaemato-
porphyrin and indican have been met with. Bile pigment is only present
when there is definite jaundice.

If the liver be regarded as an important factor in preventing sugar
passing into the circulation, it would be natural to expect to find glycosuria
in cirrhosis. But, as a matter of fact, though it is sometimes reported,
alimentary glycosuria is rare in cirrhosis, and considerable doubt exists as
to the value of alimentary glycosuria as a reliable sign of hepatic in-
sufficiency. If the view be taken that the liver is a sugar-producing organ,
the comparative rarity of glycosuria in cirrhosis, and its absence where the
liver is undergoing extensive disorganisation, as in acute yellow atrophy,
can be understood. In haemochromatosis the liver becomes cirrhotic, and
diabetes mellitus is present in the great majority of the recorded cases
(diabdte bronze), but it is due not to the hepatic change, but to a con-
comitant and extensive fibrosis of the pancreas.

Albuminuria is not present as a rule ; it may be due to organic disease
of the kidneys, such as granular or lardaceous change. In some instances it
appears to be due to changes in the renal cells set up by toxaemia, and in
such cases albumosuria has also been found. In some few instances albumin-
uria may be due to chronic renal congestion following dilatation of the
heart, or possibly to a combination of the last two factors. It has been
thought that albuminuria is more often seen in small cirrhotic livers than
in larger ones, but no dogmatic decision as to this is at present justified.

When acute changes in the liver-cells are superadded to cirrhosis, leucin
and tyrosin may appear in the urine. The urotoxic coefficient has been
found to be increased.

(Edema of the feet is often referred to the intra-abdominal pressure of
ascites impeding the flow of blood through the inferior vena cava. But this
mechanical explanation will not at any rate fit all cases, for oedema of the
feet may come on before and independently of ascites. In such cases the
toxic origin of oedema may very reasonably be invoked ; it has been sug-
gested that a poison with a lymphagogue action is produced, and that the
oedema is due to this factor. In some cases oedema may be cardiac,
and the result of dilatation of the heart and mitral regurgitation. In
an alcoholic subject the heart may dilate after a debauch. Another
possible cause for oedema of the legs is alcoholic neuritis ; a certain
degree of alcoholic neuritis is probably commoner in cirrhosis than is
generally recognised.

General oedema is very rare in cirrhosis, but oedema may creep up on to
the abdomen and appear on the back.

LIVEE, DISEASES OF 515

Symptoms. — The early symptoms in cirrhosis are referable to the
alimentary canal and indicate gastro-intestinal catarrh. This catarrh is
partly due to portal obstruction, with resulting venous engorgement of the
stomach and intestines. There is often, in addition, dyspepsia of an
alcoholic type with morning sickness, showing that the abuse of stimulants
has a good deal to do with the symptoms. Chronic pharyngitis and
laryngitis with their attendant symptoms are minor but frequent accom-
paniments of cirrhosis.

Digestion is slow and assimilation is impeded, so that the patients lose
flesh and get thin. Flatulent dyspepsia is not uncommon, and the bowels
are irregular; diarrhoea may alternate with constipation. Late in the
disease, when there is toxEemia, diarrhoea may set in and carry the
patient off.

Generally the temperature is not raised, but in cases where the disease
advances rapidly there may be continued fever, while active tuberculosis or
other complications produce a similar effect.

Hcematemesis often comes on without any evidence of gastritis ; at
other times it is immediately preceded by pain, heaviness in the abdomen,
and malaise. The patient feels faint, and shortly afterwards brings up a
large quantity of blood, often partially clotted. The blood is darker in
colour than that brought up in gastric ulcer, but not so altered as the
" coffee-ground " vomit of carcinoma of the stomach. Usually there is a
single large haematemesis, but it may be followed by a second. If hsema-
temesis is repeated several times at short intervals there is probably a bleeding
varicose vein at the lower end of the oesophagus, or a small abrasion of
the mucous membrane of the stomach ; these are the cases that may prove
fatal. In 60 cases of fatal gastro-intestinal haemorrhage in cirrhosis, Preble
found that in no less than a third of the cases death took place on the first
occasion, and in 80 per cent of the cases there were varicose veins in the
oesophagus.

Ordinarily the hsematemesis of cirrhosis does not give rise to such
severe collapse as that of gastrio ulcer, and is rarely fatal. While there
may be some general tenderness over the stomach due to gastritis, there is
no localised area where pressure gives rise to severe pain as in gastric
ulcer. Gastric and duodenal ulcer are very rare accompaniments of
cirrhosis. The bleeding may be due to gastritis, to small erosions or
abrasions, or to rupture of varicose veins in the oesophagus, or, in rare
instances, in the stomach. It is commonly assumed that there is a general
and gradual capillary oozing of venous blood from the rupture of capillaries
in the gastric mucosa, but it is probable that some inflammatory or destruc-
tive change in the mucous membrane is necessary to allow of this.

Hsematemesis would be much more frequent were it merely the
mechanical result of increased pressure in the portal circulation.

A cause of gastritis that is often overlooked and may lead to hsema-
temesis is bad teeth with pyorrhoea alveolaris ; the pus teeming with micro-
organisms is swallowed, and readily gives rise to changes in the gastric
mucous membrane.

With hsematemesis there is generally melsena ; nielsena may occur
without hsematemesis when the amount of blood poured out into the
stomach is not excessive.

Hsematemesis is usually a comparatively early symptom of cirrhosis,
and is often the first indication and warning of grave disease that the
patient receives. But it may occur late in the disease, and even prove
fatal when there is ascites.

516 LIVER, DISEASES OF

For the diagnosis of haematemesis from different causes the reader is
referred to the article " Haematemesis " in vol. iv. p. 257.

The treatment of haematemesis is absolute rest to the stomach and
perfect repose in bed. A hypodermic injection of morphia is often useful in
keeping the patient quiet.

Feeding should be carried on by the bowel, suppositories being given
every four hours, and five or six injections of 10 ounces of water in the
twenty-four hours to relieve thirst. After three or four days, if there is
no recurrence of haemorrhage, beef-tea and peptonised milk can be given
by the mouth. On the second or third day, if there is no recurrence of
haematemesis, a blue pill and a saline purge should be given to remove the
blood from the intestines.

Eecurrence of hsematemesis should be treated by return to rectal feed-
ing, and by the administration by the mouth of a dram of Ruspini's styptic
(which is largely composed of gallic acid) in 1 ounce of water.

Melcena, besides being due to gastric haemorrhage, may be due to similar
oozing from the surface of the mucous membrane of the bowel.

A certain amount of blood may be mixed with the faeces as the result of
small haemorrhages, analogous to those seen in the skin, and due to hepatic
insufficiency.

Piles are not infrequent in cirrhosis, and may give rise to haemorrhage.

Epistaxis often occurs in the course of cirrhosis ; it may pass backwards
and simulate haemoptysis. Like the small haemorrhages into the skin epis-
taxis is due to a toxaemic condition of the blood brought about by hepatic
insufficiency ; the poisons produced in the alimentary canal not being
stopped by the liver pass into the general circulation.

Oozing from the gums is due to the same cause.

Blood may be hawked from the back of the throat and be thought to
have come from the lungs. Occasionally bleeding occurs from the larynx.
Haemoptysis may be due to pulmonary tuberculosis, which is a well-recognised
complication of cirrhosis ; collapse of the bases of the lung, due to compres-
sion by ascites or by a pleural effusion, may also cause haemoptysis.

In the early stages of cirrhosis in women metrorrhagia is often seen ;
later there is generally amenorrhoea.

Jaundice. — An attack of catarrhal jaundice may occur during cirrhosis,
but continued or deep jaundice is very rare, and the black jaundice of
malignant disease is never reached. A terminal jaundice, due to acute
degenerative changes in the liver-cells, is sometimes seen.

A slight degree of icterus is, however, often seen, the conjunctivae being
tinged with light yellow for a time instead of their habitual dirty hue.

Nervous Symptoms. — In the late stages a toxaemic condition analogous
to uraemia sets in, and the patients usually become drowsy, apathetic, and
comatose ; but sometimes there is delirium, which may be so active that
there is considerable trouble in keeping the patient in bed. When drowsy
and quiet the patient becomes careless, passes his motions under him, and
it may be difficult to keep the skin of the back intact and prevent the onset
of bed-sores. Cases have been described where children have presented
symptoms like the juvenile type of general paralysis during life, with entire
latency of advanced cirrhosis of the liver. The symptoms due to a toxaemic
condition of the blood chiefly affect the brain, but slight degrees of peri-
pheral neuritis are probably often overlooked.

Complications. — As has already been pointed out, pulmonary tuberculosis
is often met with in the bodies of those dying from cirrhosis ; often there
are no clinical signs of the tubercle, but its presence should be suspected

LIVER, DISEASES OF 517

when there is fever without any satisfactory cause. Sometimes the progress
of pulmonary tuberculosis is so rapid and emphatic that it throws into the
shade the existence of cirrhosis, which is only revealed at the post-mortem.
Pulmonary tubercle and alcoholic neuritis may be found as concomitant
complications in cirrhosis, especially in women. Pulmonary tuberculosis is
less often seen in children with cirrhosis than in adults with the disease,
probably because alcoholism is less frequent in children.

Right-sided pleurisy frequently complicates cirrhosis ; it has been sug-
gested that infection may spread through the diaphragm. It should be
remembered that considerable dulness at the base of the right lung may be
due to a large cirrhotic liver, or to upward displacement of the liver by
abdominal distension without any pleural effusion. In rare instances pleural
effusions in cirrhosis are hemorrhagic ; this is due to tubercle.

Tuberculous peritonitis is another complication that is especially liable
to occur in the course of cirrhosis, and it may very easily escape detection,
the effusion being naturally regarded as that due to cirrhosis.

A number of acute infections may occur, such as erysipelas, pericarditis,
pneumonia, infective endocarditis, and especially peritonitis.

When an acute infection attacks the liver itself icterus gravis results
from the acute degenerative changes induced in the liver-cells.

Thrombosis of the portal vein shows itself by the rapid development of
ascites ; if the clotting extends into the mesenteric branches it may give
rise to melaena and a paralytic state of the bowel imitating intestinal
obstruction.

In some instances cardiac failure occurs, and may become so prominent
that the existence of cirrhosis is obscured or not detected until after death.
Occasionally sudden death results from this cause.

Diagnosis. — In the pre-ascitic stage, before haematemesis has occurred,
cirrhosis may be suspected from enlargement and tenderness of the liver,
and enlargement of the spleen, in an alcoholic subject, with dyspepsia.

When hsematemesis has occurred it must be differentiated from gastric
ulcer, and especially from that extensive and somewhat latent form of
ulcer met with in men between 40 and 50 years, and often associated
with arterio-sclerosis. Though it is easy to recognise a gastric ulcer in a
young woman with all the classical symptoms and signs, it may be very
difficult in men, for extensive ulceration may exist without much tender-
ness. These patients are more anaemic than in cirrhosis, and complain more
of pain, while the spleen is not enlarged.

In malignant disease of the stomach the tumour may not be felt ; but, in
that case, there are likely to be signs of pyloric obstruction, and hsematemesis
is scanty and like " coffee-grounds."

When ascites has supervened, the other conditions that may equally
give rise to this must be considered and eliminated {vide article " Ascites ").
The ascites of cirrhosis is peculiar in that it seldom requires tapping more
than twice, while in chronic peritonitis, and most other forms of ascites, it
may be called for again and again.

In the late stages of cirrhosis, with cachexia and emaciation, it may
be very difficult to eliminate cancer of the liver until the fluid is removed
by paracentesis; a large knobby liver with umbilication of the nodules
points to malignant disease; a small liver with splenic enlargement to
cirrhosis.

Syphilitic disease should be suspected when there are signs of syphilis
elsewhere in the body, and a vigorous course of antisyphilitic remedies
should be prescribed. But outward signs of syphilis may be wanting, and

518 LIVEK, DISEASES OF

the proof of syphilitic disease of the liver may only be found in recovery
under iodides.

When the patient first comes under observation, with some complication
such as cardiac failure, phthisis, pleural effusion, and so forth, the existence
of cirrhosis may not be suspected at first.

Prognosis. — The prognosis of cirrhosis is extremely bad at a late period
of the disease, and when emaciation and ascites have developed, the
patient's days are, as a rule, numbered.

Cases of undoubted cirrhosis, in which tapping has been followed by
improvement and latency of the disease for years, have, it is true, been met
with. If the patient's general condition and nutrition remain good, ascites
is more likely to be recovered from than in the ordinary run of cases, where
the patient is cachectic by the time ascites has appeared. The prognosis is
very much better in the early stages of the disease, and a patient who has
suffered from haematemesis may, by strict obedience to medical treatment
and directions, escape from any further symptoms. On the other hand, the
terminal symptoms of cirrhosis, such as ascites, oedema of the legs, and
toxaemia, may come on suddenly, and sometimes without any very apparent
cause.

The latency of symptoms depends on compensatory mechanisms : — (1)
the collateral circulation ; and (2), probably most important, hyperplasia of
the liver-cells.

When this compensatory hyperplasia has occurred the liver becomes
larger, while the spleen becomes smaller. There is, however, the danger
that the areas of hyperplastic liver-cells may undergo degeneration, or
become invaded by fibrosis, and, by sharing in the cirrhosis, lead to a
recrudescence of the symptoms.

The prognosis depends in great part on the patient's method and
conduct of life, and is, of course, made worse by any complication, such as
phthisis or renal disease, diseases which may kill the patient without any
marked hepatic symptoms. The activity of the kidneys, or renal permea-
bility, is an important element in the prognosis. As long as the kidneys
carry off the toxic bodies that the cirrhotic liver allows to pass into the
general circulation the patient is in a fairly satisfactory state ; but failure
of the renal excretion entails hepatic toxaemia, which is analogous to urinary
toxaemia.

Treatment. — The fibrotic condition of the liver cannot be removed by
the administration of drugs, such as iodides or chloride of ammonium.
Although the disease cannot be cured it may become latent. The objects
of treatment, therefore, should be (1) to allow the development of the
compensatory mechanisms which enable the disease to become latent ; and
(2) symptomatic.

In the first place, any factors that lead to or favour cirrhosis must be
removed. Alcohol must be cut off entirely ; on the patient's power of will
to become a total abstainer his future will largely depend. Medicines, if
necessary, should not contain tinctures, alcoholic extracts, or be flavoured
with spirituous compounds. If the patient's condition absolutely demands
alcohol, it should be taken largely diluted after meals.

The diet should be restricted to milk, of which three or four pints should
be taken daily ; it may be mixed with Vichy, Apollinaris, Vals, or soda water.
When improvement occurs fish diet may be taken. Abstinence from spicy,
rich, and irritating food is most important, as fermentation and absorption
of toxic products are thus minimised. Milk fulfils these essentials, and
is, moreover, a good diuretic. Fatty and sugary foods have the dis-

LIVER, DISEASES OF 519

advantage that they may lead to dyspepsia and the production of fatty
acids.

Meat and much proteid food, tea and coffee, are also harmful.

Intestinal catarrh and fermentation should be prevented; although
antiseptics, such as salicylate of bismuth, salol, /3-naphthol, may be
employed with this object ; it is probably better to use a simple saline,
such as magnesium or sodium sulphate with small doses of calomel,
scammony, or euonymin. Water should be taken freely, so as to stimulate
diuresis and excretion of toxic products.

Plenty of fresh air, and, unless there is ascites or some other deterring
element, moderate exercise should be recommended, so as to improve the
general health and resistance. A course at Carlsbad, Vichy, or Marienbad
may be taken with benefit.

Drugs. — Iodide of potassium is usually given, and, no doubt, does good
in syphilitic disease of the liver simulating cirrhosis. Many writers
believe it does good in genuine cirrhosis. It is better to give the less
depressing iodide of sodium. Chloride of ammonium is an hepatic stimu-
lant and may be given a trial, but it is not more successful than iodides.

Arsenic should be avoided. There is no drug that has the power of
stimulating the compensatory hyperplasia of the liver-cells.

Symptomatic treatment is necessary in hsematemesis {vide p. 516),
ascites, and in the terminal toxaemia.

Ascites. — When ascites gives rise to any embarrassment of respiration,
to collapse of the bases of the lungs, or to hsemoptysis, the abdomen should
at once be tapped. Formerly tapping was postponed as long as possible,
because peritoneal infection was sometimes thus set up, but with strict
antiseptic precautions this objection no longer holds, and paracentesis
should be done, since the mechanical or pressure effects of ascites are harmful.
The trocar should be a small one of Southey's pattern. The large trocars
formerly employed removed the fluid very rapidly and thus sometimes
produced collapse. The trocar is usually introduced in the linea alba
between the umbilicus and the pubes in a dull area ; care should be taken
to avoid puncturing a distended urinary bladder. It has been suggested
that the trocar should be introduced to the left of the middle line, so
as to avoid wounding the csecum or liver, but this is hardly necessary.
The fluid should be allowed to drain away through an india-rubber tube
for twelve to eighteen hours. During this operation a bandage or binder
should be applied to the abdomen and tightened from time to time. It
should be kept on for some days after paracentesis. Continuous drainage
has been tried, but is not successful, and may be dangerous.

When the ascites is comparatively small it is worth while trying to
remove it by purgatives and diuretics. It is probable, however, that they
largely do good by removing toxic bodies from the organism, which are the
cause of the ascites.

Saline purges, such as magnesium sulphate or jalap powder, have been
commonly employed. Strong purgatives are not without the danger that
they may set up or increase intestinal catarrh and exhaust the patient's
strength, and so do more harm than good. Calomel in \ to ^ grain doses,
euonymin, and scammony may be tried.

Diuretics. — Copaiba is often successful, but has the disadvantage that it
may set up gastric disturbance. A pill containing mercury, squills, and
digitalis is a good preparation and may be safely employed. Digitalis,
caffeine, bitartrate and acetate of potash, and spirits of juniper have been
recommended, but, with the exception of the first, are of rather doubtful

520 LIVEE, DISEASES OF

benefit. Becently urea, extract of liver substance, and asparagus have been
said to have had some success. Personally I have found urea very dis-
appointing.

The diuretic action of milk has already been pointed out. No attempt
to restrict the amount of fluid taken should be made.

At the same time that moderate purgation and diuresis is being induced,
iodide of potassium should be persisted in on the chance of the disease
being in reality syphilitic.

The surgical treatment of ascites has recently been introduced by
Morison and Drummond ; the abdomen is opened, and artificial peritoneal
adhesions set up by rubbing the opposed surfaces of peritoneum, and fixing
the omentum to the parietal peritoneum. The avowed object was to
increase the collateral circulation between the portal and the general
systemic veins {vide p. 508), but it may act by increasing the nutrition of
the liver-cells, and allowing them to undergo compensatory hyperplasia.
The operation is on its trial ; of fifteen cases submitted to this treatment
five have been cured, while improvement for a time has taken place in a few
of the remainder.

When toxaemia becomes marked very little can be done. The bowels
should be kept freely open, the kidneys should be stimulated by diuretics,
and plenty of water should be given by the mouth or by enemata. Intra-
venous transfusion is followed by temporary improvement.

Haemorrhages and itching of the skin may be combated by calcium
chloride, grs. xx. given for a few doses.

LITERATURE. — Abbott, M. Journal of Pathology, vol. vi. p. 315. — Adami. Sajous'
Annual, 1898 ; Brit. Med. Journ. 1898, vol. ii. 1215. — Boix. La foie dyspeptique, 1895. —
Chaeffard. Sem. med. May 24, 1899. — Cheadle. Lumleian Lectures, Brit. Med. Journ.
1900, vol. i. — Foxwell. The Enlarged Cirrhotic Liver, 1896. — Hanot et Gilbert. Archiv.
genirale de mid. vol. clxvi. p. 250. — Kelynack (Statistics). Birmingham Med. Review, Feb.
1897. — Lancereaex (Plastering Wines). Bull, de I'acad. de mid. 1897-98. — Morison and
Drummond. British Medical Journal, 1896, vol. ii. p. 728. — Opie (Haemochromatosis).
Journal of Experimental Medicine, vol. iv. — Pitt (Statistics). Trans. Path. Soc. vol. xl. p.
348. — Price (Statistics). Guy's Hospital Reports, series iii. vol. xxvii. p. 295. — Rolleston and
Fenton (Statistics). Birmingham Med. Review, Oct. 1896. — White, W. Hale. Guy's
Hospital Reports, 1892 ; Clinical Journal, April 26, 1899. — Yeld (Statistics). St. Bartholomew's
Hospital Reports, vol. xxxiv. p. 215.

On the Occurrence of the various Forms of Cirrhosis in

early Life

The various forms of hepatic cirrhosis that may be met with in
children have been described elsewhere, but it may be useful to summarise
the facts briefly here.

The pericellular cirrhosis of hereditary syphilis and the lesions of
tardive hereditary syphilis are fully dealt with (p. 544), and it is there
pointed out that after recovery from pericellular cirrhosis the liver is
probably left with its resistance so diminished that it may readily become
affected by ordinary portal cirrhosis, the resulting change being neither due
to syphilis nor curable by antisyphilitic treatment, but disposed to by the
influence of former syphilis, and therefore parasyphilitic and comparable to
locomotor ataxia and general paralysis of the insane. Some cases of
marked portal cirrhosis in early life may thus be distantly related, though
not directly due, to syphilis.

In rickets some slight fibrosis may occur in the liver, but it is never
marked, probably transitory ; it is hardly worth while to speak of rickety
cirrhosis.

LIVER, DISEASES OF 521

Both portal and hypertrophic biliary cirrhosis are met with in children,
and the symptoms conform fairly well to those seen in adults.

In atrophic cirrhosis there is occasionally an absence of all hepatic
symptoms and the presence of marked nervous manifestations, so that the
existence of cirrhosis is quite unsuspected during life. Such cases have
been recorded by Ormerod and Homen, but it is possible that the cases
were juvenile general paralytics with a parasyphilitic cirrhosis of the liver.

Pulmonary tuberculosis is, I believe, much rarer in portal cirrhosis of
children than in adults, but on the other hand tuberculous peritonitis is
not an infrequent complication in children.

Hypertrophic biliary cirrhosis, which, under ordinary conditions, occurs
earlier in life than portal cirrhosis, may present special features when it
occurs in infants. The biliary cirrhosis of Brahmin infants around Calcutta,
and the juvenile type of hypertrophic biliary cirrhosis described by Gilbert
and Fournier, have already been referred to. It is noticeable that some
cases of hypertrophic biliary cirrhosis in children run a very protracted
course, and that sometimes the type changes and eventually presents many
of the features of portal cirrhosis.

Marked monolobular cirrhosis accompanies congenital obliteration of
the bile ducts (vide vol. iv. p. 47), but the symptoms are those of biliary
obstruction. Cases of hepatic pseudo-cirrhosis, cardiac cirrhosis, and cardio-
tuberculous cirrhosis (vide chronic venous engorgement of the liver), are
chiefly met with in children.

LITERATURE.— Gibbons. Scientific Memoirs by Medical Officers of the Army of India,
part vi.— Hatfield. Encyclopcedia of Children's Diseases, 1889.— Ormerod. St. Bartholo-
mew's Hospital Reports, vol. xxvi. p. 57. — Grancher, Comby, et Marfan. Traite des
maladies de Venfance-, t. iii.

Degenerations and Infiltrations

Fatty Liver . . . .521
Lardaceous Liver . . . 524
Pigmentary Change . . .525

Calcareous Infiltration . . 525
Leukemic Infiltration . . 526

Fatty Liver

Signs 523

Symptoms 523

Diagnosis 523

Fatty Infiltration and De-
generation . . .521
Causation . . . .522
Morbid Anatomy . . .522

This includes the two conditions of (i.) fatty infiltration, and (ii.) fatty
degeneration. Although this article is only concerned with a pathological
increase of fat in the liver, it may be well to state what is meant by the
terms fatty infiltration and fatty degeneration.

Fatty infiltration or accumulation is an exaggeration of the physio-
logical storage of fat in the liver-cells ; fat is normally present in small
amounts in the liver-cells of young children, sometimes in healthy persons
who have died from the effects of accidents, and commonly in obesity.
Histologically, the cells at the periphery of the lobules of the liver are
first and chiefly affected, and contain globules of fat of considerable size ;
the protoplasm and the nucleus of the cell are mechanically displaced by the
fat, and are not chemically altered or degenerated. When the fat is removed
the cells return to their normal state.

In fatty degeneration the protoplasm of the liver-cell degenerates and

522 LIVEK, DISEASES OF

undergoes a retrograde metabolism ; as a result, globules of fat, at first of
small size, appear scattered throughout the cell substance. The nucleus
remains in its normal position ; after removal of the fat the cell appears
shrunken, its protoplasm granular, and the nucleus fragmentary. Fatty
degeneration may occur in any part of the hepatic lobule, and may begin
first in the central zone.

These two conditions run into each other, and in practice it is in many
cases difficult to draw a hard and fast line between fatty infiltration and
fatty degeneration. It is therefore better to speak of pathological fatty
change in the liver.

Causation. — Pathological fatty change in the liver is met with in a
number of conditions.

(1) Poisons. — Alcohol. Fatty change is very definitely related to
alcoholic excess, and experiments show that alcohol may be regarded as a
protoplasmic poison. Phosphorus, arsenic, antimony, iodoform, the mineral
acids, oxalic, tartaric, and other acids lead to marked fatty change.

Phloridzin gives rise to fatty change, which like that due to phosphorus
has been regarded as an infiltration and not a degeneration.

(2) In certain intestinal diseases where toxins are absorbed from the
alimentary canal and pass into the portal vein, fatty change in the liver is
often found ; thus it is frequently seen in gastro-enteritis and intestinal
affections of children ; in these conditions it may be said to be due to auto-
intoxication.

(3) It also occurs in hsemic infections and intoxications as a further
stage of cloudy swelling. It is seen in grave anaemias, where the deficient
blood-supply and want of oxygen are, as well as toxic bodies in the blood,
factors of importance in the production of the fatty (degeneration) change.
It is also seen in some acute infections, in diabetic coma and the status
epilepticus (Mott).

(4) In pulmonary tuberculosis a fatty liver is frequently found, and is
a striking feature in the emaciated bodies of the victims of this disease. It
is probably due to the action of toxins absorbed from the lungs. Peron's
experiments showed that the intravenous injection of sterilised cultures of
virulent tubercle bacilli lead to extensive fatty change in the liver ; Carriere's
results directly opposed Peron's, and suggest the possibility that in man
the fatty change is the result of secondary streptococcal infection. It is at
any rate unlikely that (i.) the fatty liver is due to the cod-liver oil so con-
stantly given now, since the condition was noticed before its introduction
(Wilson Fox) ; or (ii.) entirely to a deficient supply of oxygen, inasmuch as
there is no special degree of fatty change in emphysema and allied condi-
tions.

(5) Deficient blood-supply, as in anaemia, lardaceous disease, etc., probably
leads to fatty degeneration; but in grave anaemia the presence of toxic
bodies in the blood must also be considered.

Morbid Anatomy. — The liver is usually enlarged, sometimes, as in
phosphorus or iodoform poisoning, very markedly; considerable fatty
change may, however, be present in a liver of normal size. The surface is
smooth and the edges are rounded ; its consistency is usually firmer than
normal, though sometimes from post-mortem changes it is very soft.

The specific gravity is diminished, and in some instances the liver may
actually float in water. On section the knife becomes greasy, while pieces
of the liver held in a flame may splutter and burn from the large amount
of oil in the organ.

The cut surface is anaemic, yellowish white in colour, and may show

LIVEll, DISEASES OF 523

exaggeration of the lobular arrangement, suggesting fine cirrhosis. A micro-
scopic examination is sometimes required to settle the question whether
cirrhosis is present. There is often slight apparent fibrosis from atrophy of
the liver-cells.

Fatty change frequently complicates other lesions of the liver, such as
portal cirrhosis, nutmeg liver, and lardaceous disease. The histological
changes have already been described (p. 522).

Signs. — In cases where there is general obesity the liver may be made
out by percussion to be enlarged, but it may be difficult to feel the edge
distinctly, both because the abdominal walls are overloaded with fat, and
because during life the enlarged fatty liver is soft.

The skin is greasy, the tension of the pulse probably low, and the heart
sounds distant or feeble. Fat women often have remarkably small chests,
and in the dead-house the contrast between the enormous fatty covering
and the size of the thorax is striking.

In cases where a fatty liver is associated with definite disease, such
as pulmonary tuberculosis, the liver is enlarged and smooth, but is less
firm than in lardaceous disease or cirrhosis, and therefore not so easily
felt.

The spleen is not enlarged. There is no ascites or jaundice.

Addison laid stress on the condition of the skin accompanying fatty liver.
— bloodless, looking like fine polished ivory, almost semi-transparent, and
exquisitely smooth, like satin. This change was earliest seen and best
marked on the backs of the hands.

Addison also referred to recurring attacks of oedema in cases of fatty
liver, especially when the patients were alcoholic. Possibly the oedema was
due to peripheral neuritis or cardiac dilatation.

An excess of glycero-phosphoric acid in the urine derived from lecithin,
which is present in large amounts in fatty livers, has been described
(Lepine et Eymennet).

Symptoms. — The symptoms met with in cases of fatty liver are those of
the condition or disease responsible for the secondary change in the liver.
No doubt the various functions of the liver are not so well performed as
they would be if the cells were healthy, but there is no constant or pre-
eminent failure of function. If the degeneration is very acute and at the
same time extensive, the symptoms would approach those of acute atrophy,
although actually the liver is much larger than normal. But the condition
then ceases to be one of ordinary fatty liver.

The stools are light, and the biliary secretion, though it does not cease, is
probably deficient. Jaundice does not occur in uncomplicated cases, and
there is no portal obstruction, so that ascites does not occur, and there is no
enlargement of the subcutaneous or retro-peritoneal veins.

Piles are said to occur, but the diarrhoea that was formerly thought to
depend on fatty liver is probably the cause rather than the effect.

There is no pain associated with fatty liver.

Diagnosis. — Fatty liver may possibly be mistaken for —

(1) Leuksemic infiltration of the liver. — Here examination of the blood
settles any doubt.

(2) Lardaceous disease. — The liver is much firmer than in fatty liver,
and there may be signs of lardaceous disease of the kidneys (albuminuria),
splenic enlargement, or diarrhoea.

(3) A cirrhotic liver, especially for an enlarged cirrhotic liver, with
latency of the symptoms. — When there are no symptoms the diagnosis is
very difficult, and turns chiefly on the surface of the liver. If it is smooth,

524 LIVEE, DISEASES OF

fatty change is probable; while if irregular, cirrhosis is indicated. In
numerous instances fatty change is associated with cirrhosis.

(4) A displaced liver, if movable, is at once recognised, but if displaced
by some cause, such as a pleural effusion or pneumothorax that is not
detected, a further mistake is not improbable, and it might be regarded as a
large fatty liver.

(5) Enlargement of the liver due to a deep-seated hydatid cyst or
abscess. Here the liver is much more prominent and more easily felt and
mapped out, while there may be signs of pressure or fever.

Treatment. — The primary cause, such as obesity or pulmonary tuber-
culosis, and not the liver, should be treated.

LITERATURE.— Addison, T. Guy's Hospital Reports, vol. i. 1836.— Carriere. Archiv.
experiment, mid. Jan. 1897. — Fox, Wilson. Treatise on Diseases of Lungs and Pleura, p. 620.
— Lepine et Eymennet. Lyon mddical, vol. xli. p. 15. — Mott, F. W. Archives of Glaybury
Asylum, 1899. — Peron. Soc. biolog. Paris, Jan. 1897.

Lardaceous Liver

In lardaceous disease the liver is less frequently affected than the spleen
and kidneys. Thus combining the statistics of Birch-Hirschfeld, Loomis,
Dickinson, and Turner, in 645 cases of lardaceous disease the spleen was
affected in 486, the kidney in 429, and the liver in 314.

The liver is uniformly enlarged, smooth, and painless ; the edge is firm
and regular. The enlargement may be very considerable, and even reach to
the level of the iliac spines. No symptoms can be referred to lardaceous
affection of the liver apart from the general symptoms of the disease.

It has been thought that ascites may be set up by lardaceous lymphatic
glands in the portal fissure ; ascites, however, is rare in uncomplicated lar-
daceous liver, and when it does occur is probably part only of universal
oedema. Under treatment the hepatic enlargement has been known to
diminish considerably.

Lardaceous change may, however, be associated with cirrhosis, gummata,
syphilitic cicatrices, perihepatitis, or abscess. Jaundice, ascites, and pain
may be due to such conditions complicating lardaceous disease.

Lardaceous disease of the liver may be expected in a patient with signs
of lardaceous disease of other organs, such as an enlarged spleen, albumin-
uria with a low tension pulse and no cardiac hypertrophy, dropsy, anaemia,
and diarrhoea, where the liver is smooth and enlarged.

Signs of past suppuration, of syphilis, or chronic phthisis are important
in concluding that in a given case hepatic enlargement is due to the
lardaceous change.

A lardaceous liver must be distinguished from other causes of painless
and uniform enlargement.

In the absence of anaemia, of some degree of wasting, and of the ante-
cedents of the lardaceous change — prolonged suppuration and syphilis — of
evidence of concomitant lardaceous change in the kidneys and intestines as
shown by albuminuria, oedema, and diarrhoea, the probabilities are against
the lardaceous change.

Fatty liver in phthisis may imitate lardaceous change in the liver, but
the organ is not so firm, and other evidences of lardaceous disease are
wanting.

A deep-seated hydatid cyst may push the liver forward, and give rise
to enlargement like that of the lardaceous organ, but the general health is
good, no cause for the change is forthcoming, and the other symptoms of
lardaceous disease are absent.

L1VE11, DISEASES OF

525

A large fatty cirrhotic liver will probably be tender or accompanied by
pain or definite symptoms of cirrhosis such as heematemesis.

In leukaemia the liver is often considerably enlarged, painless, and
smooth ; this is more frequently seen in the lymphatic than in the spleno-
medullary form. Examination of the blood will at once settle any question
between these two diseases. In the rare event of lymphadenoma giving
rise to considerable hepatic enlargement, evidence of enlargement of the
lymphatic glands elsewhere in body will probably be forthcoming, and the
temperature may be hectic.

When lardaceous disease is combined with gummata or syphilitic
cicatrices, the diagnosis from malignant disease may be difficult, and
depends on the effect of antisyphilitic treatment, the evidence of syphilis
elsewhere, and the more chronic course of the disease.

The treatment of lardaceous liver is that of lardaceous disease generally ;
when combined with syphilis or cirrhosis the lines of treatment are those
of the complicating disease.

For the pathology, morbid anatomy, and other points the reader is
referred to the article on " Lardaceous Disease."

Pigmentation of the Livee

In HEMOCHROMATOSIS

In Anthracosis

525

Microscopic Pigmentation in

Various Conditions . . 526

Hemochromatosis. — In the condition described by v. Eecklinghausen
as hemochromatosis there is very extensive destruction of the red blood
corpuscles and deposit of pigment in various parts of the body, especially in
the liver, pancreas, and skin. It has been suggested by Adami that this
destruction of the red blood corpuscles is due to bacterial infection, and by
Meunier that there is a toxic factor analogous to toluylenediamine at work.
The deposit of pigment in the liver and pancreas sets up chronic interstitial
fibrosis. When the fibrosis in the pancreas has reached a certain stage
diabetes is set up ; the cases of bronzed diabetes described by Hanot and
Chauffard, of which Anschiitz has collected twenty-four examples, all in
men, are therefore the final result of hemochromatosis.

The liver is usually enlarged, presents the naked-eye and microscopic
appearances of multilobular cirrhosis, and is pigmented. The pigment
occupies the liver-cells, which become degenerated, the cells in the periphery
of the lobule are chiefly infiltrated, but the entire lobule may be affected.
The pigment is also found in the fibrous tissue of the organ. The pigment
is of two kinds — (i.) iron containing hemosiderin ; (ii.) a yellow iron-free
pigment, termed by v. Eecklinghausen hemofuscin.

The hepatic artery shows endarteritis obliterans.

LITERATURE. — Adami. Journ. American Med. Assoc. Dec. 23, 1899.— Anschutz.
Deutsch. Archivf. klin. Med. 1899, lxxii. 411. — Hanot and Chauffard. Rev. de mid. 1882,
ii. 385. — Meunier. These, Paris, 1898. — Opie. Trans. Assoc. American Physicians, vol.
xiv. p. 253.

Antheacosis, Silicosis, etc. — In rare instances particles of carbon and
other foreign substances are found in cirrhotic livers. Cases have been
described in coal and copper miners and stone-masons. Particles of silver
have also been detected in the liver after its medicinal administration.

These conditions are all very rarely seen, and have no clinical importance.

LITERATURE.— Welch. Johns Hopkins Hosp. Bull. 1891. — Lancereaux. TraiU des
maladies du foie et dn pancreas, p. 340. — Adami. Sajous' Annual, 1898, vol. ii. p. 313. —
Frommann. Archivf. path. Anat. u. Physiol. Berlin, 1860.

526 LIVEE, DISEASES OF

Microscopic pigmentation of the cells of the liver is seen in a number
of conditions : —

(i.) Pernicious Anaemia. — The cells of the peripheral zones of the lobules
contain free iron. When acted upon with ferro-cyanide of potassium and
dilute hydrochloric acid, the pigment turns of a bluish green colour.

(ii.) In some causes of leukaemia a similar infiltration of the cells of the
peripheral parts of the lobules of the liver with free iron is seen. I have
also seen the same pigmentation in lymphadenoma.

(iii.) In chronic venous congestion the " nutmeg " liver shows haemoidin
in and around the cells surrounding the intra-lobular vein. This deposit
of pigment must be distinguished from that of pernicious anaemia, from
which it differs both in its situation and micro-chemical reactions.

(iv.) In malarial cachexia — a condition approaching that of haemo-
chromatosis — the liver-cells may become pigmented and atrophied. This
pigmentary change may be associated with cirrhosis.

(v.) In some cases of cirrhosis and of new growth in the liver the cells
may show pigmentation without the existence of any general deposit of
pigment in the body. Possibly this may be due to local chronic venous
congestion, haemorrhages, or haemolysis.

(vi.) In biliary obstruction the liver-cells are degenerated, and occupied
by granules of bile pigment.

(vii.) Local pigmentation with blood pigment occurs around the scars of
old abscesses, gummata, and sometimes in the immediate neighbourhood of
innocent naevi — " melanotic angioma."

Calcification of the Liver. — This condition is of no clinical importance,
though pathologically interesting. It may be briefly referred to under two
heads : —

(1) Primary Calcification. — This is extremely rare in man, but it is not
infrequent in horses to find primary calcification of the branches of the
hepatic artery. It has, however, been seen around the hepatic arteries in
chronic interstitial nephritis (Brill and Lebman), and in a case of tuberculous
hip disease, where it was thought to be due to the deposit of salts absorbed
from the affected bones (Babes).

(2) Secondary calcification in gummata, in the cicatrices of old abscesses,
and in the walls of hydatid cysts, is by no means uncommon. Calcification
also occurs in the walls of chronically inflamed gall-bladders. A re-
markable case of diffuse calcification of the liver which had to be cut with
a saw (Targett) was possibly secondary to syphilitic change.

Carrel has recorded a case where laparotomy was undertaken with the
diagnosis of calcified gall-bladder, and a calcified psorospermial tumour was
found.

Sometimes hard masses are found embedded and encysted in the liver
substance. They are generally intra -hepatic biliary calculi due to drying up
of the contents of cystic dilatations of the bile ducts.

LITERATURE. — Babes. Virchow's Archiv, Bd. cv. S. 511. — Brill and Lebman.
Journ. Experim. Med. 1899. — Carrel. Lyon medical, t. xciii. p. 89. — Targett. Trans.
Path. Soc. vol. xl. p. 123.

Liver in Leukemia or Leucocyth^mia

The liver is frequently very greatly enlarged in cases of leukaemia ;
5 or 6 lbs. is a common weight for the organ, but it has been found to
weigh more than double this. Enlargement of the liver chiefly occurs in
lymphatic leukaemia, the rarer form of the disease. There may be very

LIVER, DISEASES OF 527

advanced spleno-medullaiy leukaemia without any manifest hepatic enlarge-
ment.

The liver is smooth and uniformly enlarged, the increase in size depends
on infiltration of the portal spaces with leucocytes ; the infiltration can
sometimes be easily seen around the larger portal spaces with the naked
eye. In addition the individual lobules become separated from each other
by crowds of leucocytes, so that the lobules are definitely outlined. The
leucocytic infiltration is not limited to the portal spaces or, indeed, to the
peripheral parts of the lobules, for the capillaries inside the lobules become
stuffed with leucocytes, and in some cases the leucocytic infiltration of the
lobules is very widespread. The liver-cells, especially in the centre of the
lobule, show the effects of impaired nutrition, and may be fatty or atrophied.
At the periphery of the lobule the liver-cells are sometimes seen to be in-
filtrated with free iron as in pernicious anaemia. Cirrhosis does not occur as
the result of leukaemia. In some instances small white nodules like
tubercles are seen scattered through the liver ; microscopically they are
composed of accumulations of leucocytes.

In the later stages of leukaemia ascites is not uncommonly present; it has
been suggested that this maybe due to pressure of leucocytic infiltration on the
intra-hepatic branches of the portal vein, or to pressure of enlarged glands in
the portal fissure on the portal vein. But it seems to me more probable that
it is due to some concomitant chronic peritonitis and to the cardiac debility
and altered blood state. It is possible that ascites might be in some degree
determined by thrombosis in the terminal branches of the portal vein in
the liver.

The diagnosis of leukaemic infiltration of the liver depends on an
examination of the blood. This should be done in a doubtful case of pain-
less hepatic enlargement, in order to prevent the disease being regarded as
lardaceous disease, and treated with iodide of potassium.

Prognosis. — As leukaemic enlargement of the liver is a more constant
result of the lymphatic form, and as this is more rapidly fatal than the spleno-
medullary variety, the prognostic value of hepatic enlargement in leukaemia
is of bad omen.

The treatment is of course that of leukaemia.

Innocent Tumouks

Adenoma of the Liver —

(i.) True . . . .527

(ii.) Multiple Adenoma in

Cirrhosis . . .528

Angioma ..... 530
Lipoma, Teratoma, etc. . .531

Adenoma of the Liver

This subject is divided into two — (1) true adenoma, (2) so-called
multiple adenomata, which may be considered as a compensatory hyperplasia
of the liver-cells occurring in cirrhosis of the liver.

True Adenoma. — An innocent encapsuled growth of epithelial cells may
occur in the liver, but is decidedly rare ; pathologically they are of great
interest, but clinically they seldom attract attention.

True adenomata may theoretically be divided according to their
structure into —

(i.) Those composed of liver-cells, or of cells derived from the ordinary
cells of the hepatic parenchyma.

(ii.) Those derived from the bile ducts.

528 LIVEK, DISEASES OF

(iii.) Those due to the inclusion of adrenal " rests."

(i.) An adenomatous tumour composed of liver -cells, apart from the
multiple growths of this kind seen in association with cirrhosis, is very-
rare. Such growths may be spoken of as acinous adenomata in contra-
distinction to those derived from the bile ducts. Mahomed described a
localised collection of cells surrounded by a fibrous capsule embedded
in the liver, which was " nutmeg " ; the tumour did not share in this general
change. I have seen one similar specimen. Hale White refers to an
adenoma 1£ inch in diameter projecting from the surface of the liver ; the
specimen is in the Guy's Hospital Museum. Specimens have also been
described by Engelhardt and others.

Possibly these tumours, which are pathological curiosities, may be due
to some piece of liver substance separated during foetal life from the main
mass of the liver becoming subsequently embedded in the organ. Not
infrequently small projections of liver substance, miniature lobes, are seen
on the under surface of the liver; if these became implanted in the
substance of the liver, the appearance of an encapsuled adenoma, composed
of liver -cells, would be produced. Cristiani refers to the existence of
multiple nodules of hepatic tissue embedded under Glisson's capsule, which
have been explained as congenital, and due to the inclusion of tiny lobes.

Multiple areas of hyperplasia of the liver-cells or adenomatous forma-
tions have been seen in a nutmeg liver without any cirrhosis (Jacobi).

(ii.) An adenomatous tumour derived from the bile ducts. A papilloma
springing from the inside of the extra-hepatic bile ducts would come under
this heading.

At present tumours arising from the bile ducts, indenting and displacing
but not invading the surrounding liver substance, concern us ; they may be
described as tubular adenomata. They may be single or multiple.

Single. — A single adenoma of the bile ducts may reach a size sufficient to
imitate a tumour such as a hydatid or floating kidney. Cases have been
recorded by Keen, Koenig, and Schmidt. Keen removed a cystic adenoma
thought to be derived from the bile ducts from a woman aged 31 in 1891 ;
as she was alive in 1899, the exceptional nature of the growth cannot be
explained by supposing it to be a carcinoma. Clinically it was thought
to be a floating kidney.

Multiple. — In rare cases multiple small tumours are met with, imitating
the structure of bile ducts (v. Hippel).

It has been thought by some that the condition of multiple cystic
disease of the liver is really a fibro-adenoma derived from the bile ducts.

(iii.) Possibly an included adrenal rest might give rise to a tumour
that would be best described as an adenoma.

LITERATURE. — v. Bergmann. Beitrdge zu Centralblatt fur Chirurg. — Cristiani.
Journ. de Vanat. et phys. 1891, p. 271. — Engelhardt. Deutsch. Archivf. klin. Med. Bd. lx.
Hft. 6. — v. Hippel. Virchow's Archiv, Bd. cxxiii. S. 473. — Jacobi. Trans. Assoc. Amer. Phys.
vol. xii. p. 493. — Keen. Boston Medical and Surgical Journal, 1892, vol. i. 404 ; Annals of
Surgery, 1899, p. 267. — Mahomed. Path. Soc. Trans, vol. xxviii. p. 144. — Paul. Path. Soc.
Trans, vol. xxxvi. p. 238. — "White, "VV. Hale. Allbutt's System of Medicine, vol. iv. p. 210.

Multiple Adenomata in Cirrhosis

Synonyms. — Cirrhosis complicated with adenoma ; Cancer with cirrhosis ;

Nodular cirrhosis.

History. — This condition was studied by Eokitansky, Kelsch and
Kiener, Sabourin, Cornil and Eanvier, Hanot, and others.

LIVEE, DISEASES OF 529

Nature of Multiple Adenomata. — Cornil and Eanvier regarded the de-
velopment of the adenomatous tumours as a complication of pre-existing cir-
rhosis. Hanot and Gilbert, on the other hand, believed the growths to be a
special form of carcinoma, and in common with Lancereaux regarded the
fibrosis of the liver as secondary to the irritation set up by these growths.
Brissaud speaks of multiple adenoma as being a kind of half-way house
between primary carcinoma and cirrhosis, while other writers (Sabourin,
Engelhardt) regard the production of adenomata as due to the same causes
that give rise to cirrhosis, but acting on the epithelial instead of on the
fibrous part of the organ. In dogs tumours due to hyperplasia of the liver-
cells, and probably set up by infection, are far from rare ; a few cases of a
similar nature without any cirrhosis have been described in man.

These multiple growths are, I believe, practically always part of cir-
rhosis ; they are exaggerations of the hobnails seen in ordinary cirrhosis,
and further represent an attempt at compensation on the part of the more
healthy liver cells which have undergone multiplication (compensatory
hyperplasia), and thus account for the increased size of the hobnails.

It is when these hobnails undergo fatty degeneration and necrosis, and
appear white on section, that they are particularly liable to attract atten-
tion, for when this change has occurred they do not, unless bile-stained,
suggest cirrhosis, but resemble multiple new growths. Fatty change and
necrosis of the hyperplastic nodules are particularly likely to occur when
thrombosis of the portal vein is superadded to cirrhosis. Hence the fre-
quency with which portal thrombosis is recorded as associated with
multiple adenoma, cancer with cirrhosis, etc. Thus in 15 cases of so-called
adenoma of the liver that were analysed by Dr. LI. Powell, no less than
9 had thrombosis of the portal vein.

Those who regard the condition as one of primary carcinoma of the
liver adduce the presence of hepatic cells in the portal vein and thrombosis
as further proof of its malignant character. But the presence of hepatic
cells in the portal vein does not prove that the growth is malignant, for the
hobnails being poorly nourished, and having by rapid proliferation outgrown
their blood-supply, soften down, and by discharging into the portal vein
or hepatic veins may induce thrombosis.

The proliferation of the liver-cells may be due to one of two causes —
very possibly to each of the causes at different stages of the disease.

(i.) The multiplication of the hepatic cells in the hobnails may be due
to the same poison that stirs up the connective tissue of the liver to
proliferation ; this would be the case especially in the early stages of the
disease. In cases of poisoning by mussels similar nodules are produced,
evidently directly due to the irritation exerted by the poison.

(ii.) The multiplication of the liver -cells may be an attempt at com-
pensation to make good the functional activity of the liver as a whole
which has been greatly reduced by the destruction of hepatic tissue.

It is a priori very reasonable to believe that the hyperplasia of liver-
cells might become so vigorous as to pass into carcinoma. Probably this does
occur, and so accounts for cases of multiple primary carcinoma of the liver.
My own belief is that the cases described as multiple adenoma are all
primarily cirrhosis, and that many of the cases of " cancer with cirrhosis "
recorded by the French are not necessarily anything more than advanced
cirrhosis, with hyperplasia of the liver-cells in the hobnails and a terminal
thrombosis of the portal vein.

Morbid Anatomy. — The appearance of the liver is very striking, and
suggests multiple secondary new growths, gummata, or even caseous
vol. vi 34

530 LIVEK, DISEASES OF

tubercle. The surface of the liver shows numerous projecting nodules,
which, however, are not umbilicated. They are white on section, usually
dry and friable, but may, especially when there is associated venous throm-
bosis present, be softened. The surrounding liver substance may be deeply
congested, so that the contrast between the hobnails and the rest of the
liver still further suggests secondary malignant disease. The liver is usually
somewhat enlarged in size, but may be smaller than natural.

The portal vein is frequently thrombosed, and microscopic examination
of the clot may show liver cells due to the discharge of one of the softened
hobnails into the vein. Sometimes similar thrombosis is seen in the hepatic
veins.

The lymphatic glands in the portal fissure are not enlarged.

Microscopically the liver shows marked cirrhosis ; the masses that to
the naked eye suggested new growth being seen to be altered liver -cells
surrounded by a fibrous capsule ; the interstitial tissue shows the appearance
of pseudo-bile canaliculi, advancing cirrhosis, and sometimes extravasated
blood. The normal trabecular arrangement of the liver-cells is lost ; the cells
are concentrically arranged, the more external layers being often flattened
a,s if from pressure. The liver-cells vary somewhat in size ; often they are
large, occasionally they are multinuclear ; the active karyokinesis of the
nuclei is an important evidence of hyperplasia. Fatty degeneration of the
cells and haemorrhages may be met with, especially when thrombosis of
the portal is present.

The symptoms of multiple adenomata are those of the disease of which
it is only an epiphenomenon, viz. common cirrhosis. It is found in a high
proportion of those cases where, at the autopsy, cirrhosis with thrombosis of
the portal vein is revealed.

LITERATURE. — Cornil and Ranvier. Manuel d'histologie pathologique, vol. ii. p.
438. — Engelhardt. Deutsch. Archivf. klin. Med. Bd. lx. Hft. 6. — Sabourin. Rev. de mid.
1884, p. 321. — Schmieden. Virchow's Archiv, Bd. clix. S. 290.

Angioma

The liver is more often the site of angiomata than any other viscus, but
their occurrence is not common. Lancereaux, in an extensive experience,
has seen twenty-five examples. They are more frequent in cats' livers.

They are usually single, but, like other innocent tumours, they may be
multiple, and other organs besides the liver may be involved.

Though they may be congenital they are more often seen in patients of
advanced years, and are then probably due to a combination of congestion
and atrophy of the liver-cells. In early life they have occasionally reached
a considerable size.

Angiomata are found immediately under the capsule of the liver, and
most often on the convexity of the right lobe near the falciform ligament.
They are of a deep red colour, at first sight like hemorrhagic infarcts,
After death they are collapsed and somewhat depressed below the rest of
the organ. As a rule the angioma fades gradually into the surrounding
liver substance, but sometimes it is encapsuled by fibrous tissue. The sur-
rounding tissue may be stained by blood pigment (melanotic angioma). The
fibrous trabecular sometimes become much thickened (fibrous angioma), and
so tend to lead to obliteration of the angioma. Thrombosis and organisation
of the blood-clot in them may occur. It is possible that in some instances
degenerative changes may result in an angioma becoming transformed into a
serous cyst. Structurally they are cavernous angiomata.

LIVER, DISEASES OF 531

They can be injected from the hepatic artery and from the hepatic and
portal veins.

In a few cases an angioma of the liver is sufficiently large to give rise
to signs of its presence. In a table of 75 cases compiled by Keen, where
resection of the liver for various neoplasms had been performed, 4 were
angiomata.

No distinctive signs or symptoms can be put down to their presence.
It has been suggested that murmurs or venous hums heard over the liver
may be due to them, but there is little proof in support of this view.

The only satisfactory treatment for the rare cases where there is a
definite tumour is removal by the surgeon.

LITERATURE. — Hanot et Gilbert, fitude des maladies dufoie, p, 341. — Keen. Annals
of Surgery, Sept. 1899, p. 276. — Lancereaitx. TraiU des maladies du foie et die pancreas,
p. 528!

Lipoma, etc.

Genuine fatty tumours are not met with in the liver, but detached
appendices epiploicee may become indented on the convexity of the liver
by the pressure of the diaphragm, and appear to be incorporated with
the organ.

Localised areas of extreme fatty change in the liver-cells are sometimes
seen as the result of vascular disturbances and microbic activity, but they
have no resemblance to real fatty tumours.

A few instances of myxomatous tumours in the liver have been described,
but it appears probable that they were really myxo-sarcomata and not pure
mucous tumours.

Multiple congenital fibromata on the sympathetic nerves have been
observed in the liver. The other recorded fibromata in the liver are probably
either syphilitic, especially the remarkably fibrous formations described in
hereditary syphilis by Marchant, or fibro-sarcomata.

Teratoma. — A unique specimen of a primary teratoma of the liver has
been recorded by Musick. Implantation of a dermoid cyst on the surface
of the liver, due to rupture of an ovarian dermoid, was described by Hulke.

In 10 cases of malignant abdominal teratoma ta collected by Montgomery
there were 4 in which secondary growths occurred in the liver. This
subject, however, belongs rather to the section on secondary malignant
disease of the liver (see p. 552).

LITERATURE.— Hulke. Trans. Path. Soc. vol. xxiv. p. 157. — Montgomery. Journ*
Experiment. Med. May 1898. — Musick. Joum. of Pathology and Bacteriology, vol. v. p. 128.

Cysts of the Liver

Various kinds of cysts are met with in the liver.

(1) Parasitic cysts, hydatids, etc.

(2) Simple serous cysts, usually single, or present in small numbers.
In size they are generally small ; exceptionally, they are sufficiently large
to be detected clinically. Possibly some of these latter are in reality sterile
hydatid cysts. The walls of these cysts are smooth, and are made up of a
fibrous capsule lined by epithelium. In the larger cysts the epithelium may
be wanting ; in the smaller ones it may be columnar, cubical, or flattened ;
ciliated epithelium has been met with, and has been thought to point
to their origin from embryonic bile ducts (Musick). The cysts often contain
the remains of dissepiments, showing that two or more originally separate
cysts have united.

532 LIVEK, DISEASES OF

The cysts are probably due to local obstruction and distension of bile
ducts ; it is noticeable, however, that cysts are very rare in cirrhosis.

In the early stage bile is probably present, but disappears as time
advances ; the fluid may be clear, straw-coloured, green, or, from hemorrhage
into them, reddish brown.

Other possible, but not very probable, origins for cysts are changes in
the mucous glands of the bile ducts, dilatation of lymphatics, or degenerative
changes in nsevi.

The fluid is albuminous, and may contain blood or epithelial cells,
hematoidin, bile pigment, cholesterin, or tyrosin.

Sometimes a few serous cysts in the liver are found to be associated
with granular and cystic kidneys. Such cases form a transitional step to
the multilocular cystic disease of the liver described below.

When, as is very rarely the case, a serous cyst is sufficiently large to
give rise to clinical signs, it is indistinguishable from a hydatid cyst, and
should be treated in the same way.

(3) In long-standing biliary obstruction the bile ducts in the liver
become greatly dilated ; at first they contain bile, but after a time they are
found to be distended with clear mucous fluid.

(4) Pseudo-Cysts. — By the softening of adenomatous masses in cirrhosis
cystic cavities containing degenerated liver-cells may result. Pseudo-cysts
may also be produced by degenerative processes in masses of secondary
malignant disease. In some instances of softened masses of growth the
appearances are exactly like those of cysts. This has been observed in
squamous-celled carcinoma and in sarcoma.

(5) Cystic adenomata of the bile ducts have in very rare instances been
described (vide " Adenomata," p. 528).

(6) In tuberculous disease involving the bile ducts cavities formerly
spoken of as cysts may occur.

(7) Primary dermoid cysts do not occur in the liver ; but from rupture
of an ovarian dermoid, implantation on the surface of the liver has been
known to occur (Hulke).

Multilocular Cystic Disease. — In this disease the liver shows multitudes
of cysts, and thus differs from the serous cysts which are few in number or
even solitary.

It is usually met with late in life ; in 26 cases collected by Still, 17
were over 50 years of age, 4 over 70, while the youngest adult was 39. A
very few cases (3 or 4) have been met with in infants or still-born children
who may be the subject of numerous malformations.

It occurs more often in women than in men, according to Still in the
proportion of 3 to 1 ; of 28 cases 21 were in females.

Cystic disease of the liver is always accompanied by a similar and
nearly always more advanced change in the kidneys. Cystic kidneys, how-
ever, are often met with without any manifest cystic change in the liver.

Pathogeny. — The mechanism by which cystic disease of the liver is
brought about has given rise to a good deal of discussion. Space does
not admit of a re'sume' of the subject, but the following views may be
mentioned : —

(1) That it is an irritative or inflammatory process leading to peri-
cholangitic fibrosis, and to dilatation and proliferation of the ducts
themselves.

(2) That there is a diffuse new formation — a fibro-adenoma of the
ducts.

(3) That vacuolation of the liver cells occurs and by fusion forms cysts.

LIVER, DISEASES OF

533

(4) That the condition is a malformation (Still). This view is analogous
to Shattock's theory that congenital cystic disease of the kidneys is due to
persistence and cystic dilatation of the mesonephrosis, the real kidney
substance being included in and compressed by the foetal persistence. Still
believes that the cysts are derived from columns of hypoblast cells forming
part of the original duodenal diverticulum, and not from the bile ducts.

Personally, I regard cystic disease as due to an irritative or inflamma-
tory process around the bile ducts which gives rise to their dilatation.

Morbid Anatomy. — The liver may be greatly enlarged, though this is by
no means always the case. The organ is riddled with cysts of various sizes
up to that of a hen's egg ; the larger ones are probably due to union of
previously separate ones. The contents of the cysts may be clear or blood-
stained, but do not contain bile pigment. The larger bile ducts and the
gall-bladder are normal. In infants the cysts may be so small as to be
overlooked unless a microscopic examination is made ; the liver in these
instances is not enlarged, but the fibrous tissue of the portal spaces is
manifestly increased.

Microscopically the cystic spaces are lined by columnar or cubical
epithelium with an underlying layer of well -formed fibrous tissue; in
children branching tubes surrounded by fibrous tissue can be well seen
spreading out from the portal spaces. In adults the fibrous tissue is old.
The liver cells may show an appearance suggesting vacuolation.

Clinically cystic disease of the liver is usually overshadowed by the
accompanying renal disease, and only discovered at the autopsy. The
symptoms are those of chronic renal disease and arteriosclerosis. In some
instances the liver may be recognised as enlarged, and has even simulated
an ovarian cyst. If enlargement of the liver be found in a case where the
kidneys are palpable as cystic tumours cystic disease is highly probable.
The renal enlargement is very likely to be regarded as hydronephrosis.

The treatment and prognosis are those of the renal disease.

LITERATURE.— Serous Cysts: Sharkey. Trans. Path. Soc. vol. xxxii.— Waring.
Surgical Diseases of Liver, p. 149. Cysts due to Degeneration of Malignant Disease :
Sharkey. Trans. Path. Soc. vol. xxxv. p. 374. — Thomson. Practitioner, Oct. 1899. —
Voelcker. Trans. Path. Soc. xlvii. p. 43. Dermoid : Hulke. Trans. Path. Soc. vol. xxiv.
p. 157. Multilocular Cystic Disease : Bristowe. Trans. Path. Soc. vol. vii. p. 229. —
Claude. Bull. soc. ant. Paris, 1896, p. 109. — Kanthack and Rolleston. Virchow's
Archii;, Bd. cxxx. S. 488.— Pye Smith. Trans. Path. Soc. vol. xxxii. p. 112.— Sabourin.
Archiv. ale physiolog. vol. xiv. — Still. Trans. Path. Soc. vol. xlix. p. 155.

Tubercle .

Syphilis

Acquired

Hereditary

Tardive

Infective Granulomata

533 Parasyphilitic

^^i Cirrhosis ■

537

542 Lymph adenoma .

544 Actinomycosis .

Multilobular

545
546

546

Introduction

Miliary Tuberculosis
Local Tuberculosis

Hepatic Tuberculosis
. 533

534
534

(a) Involving the bile ducts.
Tuberculous Cavities or
Tuberculous Cholangitis . 535

(b) Not involving the ducts.
" Solitary Tubercle" . 536

Tuberculous disease of the liver is of little clinical importance.
Inasmuch as it gives rise to no characteristic symptoms it cannot be

534 LIVEE, DISEASES OF

diagnosed during life, except in generalised tuberculosis, and then only on
the grounds that the liver is in most instances affected along with the rest
of the body.

The infrequency with which tuberculous lesions, other than miliary
tubercles in the course of generalised tuberculosis, are found in the liver
might suggest that the liver is specially inimical to the growth of the
tubercle bacillus. It has, however, been shown experimentally by Sargent
that the bile is not more antagonistic to tubercle bacilli than to other
micro-organisms.

The most probable explanation why tubercle of the liver is com-
paratively rare, except as part of generalised tuberculosis, is that the liver
does not lie in the direct line of the lymphatic vessels carrying lymph and
tuberculous infection from the intestines. If it were the recipient of the
lymphatics of the intestines it would probably suffer as frequently as the
mesenteric glands. The lymphatic vessels in the portal fissure convey
lymph out of the liver towards the lymphatic glands at the hilum, hence
tuberculous infection from the intestine would have to extend against
the lymph stream. This does take place in rare instances.

Hepatic tuberculosis may be divided into

(i.) Miliary tuberculosis, part of a general hsemic infection.

(ii) Local tuberculosis

(a) Involving the bile ducts.

(b) Solitary tubercle, not involving the bile ducts.

Miliary Tubercles in Generalised Tuberculosis. — In generalised tuber-
culosis the liver is practically always affected, though sometimes the
miliary tubercles are few and difficult to detect. More recent and careful
observations tend to show that the liver is very frequently affected in
tuberculous disease of other parts of the body ; thus it is said that miliary
tubercles are present in the liver in 50 per cent of the fatal cases of
phthisis (Zehlen) ; this roughly corresponds with the frequency of tuber-
culous ulceration of the intestines in phthisis.

In generalised tuberculosis the bacilli reach the liver by the hepatic
artery, and give rise to a widespread eruption of gray miliary tubercles.

These gray tubercles, which are better seen on the surface of the liver
than on section of the organ, are situated inside the lobules, and thus differ
from the local tuberculous formations found in the portal spaces.

The liver is rather increased in weight and somewhat swollen. There
may be some recent inflammation of the capsule of the organ due to the
irritation of miliary tubercles.

There are no clinical signs or symptoms that can be relied upon to
indicate the presence of miliary tubercles in the liver. Jaundice has
occasionally been observed to coincide with the development of miliary
tubercle in the liver in the course of phthisis and generalised tuberculosis ;
but this is so rare, and miliary tuberculosis so common, that it is an
interesting rather than a valuable observation. The onset of jaundice in
tuberculosis would certainly suggest hepatic infection, but the absence of
jaundice would not contra-indicate its existence. When tubercles are
present on the capsule auscultation may reveal a friction rub.

Local Tuberculosis. — Under this heading come the cases where tuber-
culosis is more chronic, and leads to more advanced changes than in miliary
tuberculosis.

A few words may be said about the sources of infection.

The weight of evidence is in favour of the view that the bacilli are
derived from the intestinal tract, and carried to the liver by the portal

LIVER, DISEASES OF 535

vein. Sargent insists on the occurrence of tuberculous pylephlebitis and
thrombosis in the portal spaces as a prelude to the development of tuber-
culous foci.

It has been suggested that tubercle bacilli from the duodenum pass up
the bile ducts, work their way through the mucous membrane of the ducts
into the portal spaces, and there give rise to the formation of caseous
tubercles. This view, which on the face of it was improbable from the
absence of motility on the part of the tubercle bacilli, has been disproved
by Sargent's experiments of injecting tubercle bacilli into the bile ducts ;
these showed that unless the walls of the ducts were previously damaged,
as by ligature, they did not allow tubercle bacilli to pass through them. It
is noticeable that the extra-hepatic ducts are not affected by tubercle except
in the rarest instances, and that there is no condition of ascending or
descending tuberculous cholangitis to correspond with tuberculous disease
of the ureter.

A tuberculous gland in the hilum of the liver has been known to burst
into the common bile duct.

It is doubtful whether tubercle is often conveyed into the liver by means
of the lymphatic vessels, though tuberculous lymphatic glands in the hilum
of the liver are, it is true, sometimes seen in cases of tuberculous enteritis.

It is also unlikely that tubercle bacilli pass in through the capsule in
cases of tuberculous peritonitis sufficiently far to set up the tuberculous
deposits.

In some cases, tubercle bacilli in small quantities reach the liver by the
hepatic artery — just as they are conveyed to bones that later become
affected with tuberculous osteitis, without any accompanying acute general-
ised tuberculosis — and produce a local caseous focus of a chronic character
in the liver.

Tuberculous Cavities in the Liver

Synonyms. — Local tuberculosis in connection with the bile ducts ; Tuber-
culous cholangitis ; Tuberculous pericholangitis.

This condition is probably not nearly so rare as the recorded cases lead
one to suppose. The tubercle bacilli reach the liver by the portal vein,
being obtained from the intestines, which in most of the cases show tuber-
culous ulceration. Sargent states that the intra-hepatic branches of the
portal vein show tuberculous pylephlebitis and thrombosis, and that, at a
later stage, tubercles develop in the portal spaces.

The tubercles inside the portal spaces after reaching a fair size caseate,
soften down, and eventually eat their way into the bile duct, into which
they discharge their caseous contents in the same way that a pulmonary
vomica opens into a bronchus. A local tuberculous cholangitis is thus
secondarily brought about by the invasion of the duct from without ; the
tuberculous change does not spread to the large extra-hepatic ducts. The
communication between the duct and the emptied caseous cavity allows
bile to enter into and stain its walls.

The liver is usually somewhat larger than natural, and on section shows
a number of white caseous areas or of bile-stained cavities with caseous
walls. In the earlier stages, before the tubercles have opened into the ducts,
the tuberculous material is firm, and resembles and is therefore sometimes
regarded as lymphadenoma ; in the later (excavitation) stage, when it has
opened into a bile duct, its walls have a greenish-yellow colour from bile-
staining, and exceptionally of a purple colour from haemorrhage. In their
early stage the tubercles may be \-\ inch in diameter while the cavities

536 LIVEE, DISEASES OF

subsequently developed are larger, and may measure as much as an inch or
even two inches across.

Structurally the masses are enclosed in a fibrous capsule representing
the fibrous tissue of the portal space, and containing caseating granulation
tissue surrounding a space which in its turn can be seen opening into a bile
duct ; the epithelium of the bile duct is usually well preserved except at the
point where it has been destroyed by the perforation from without. The
tuberculous process is therefore pericholangitic, not cholangitic.

Symptoms. — Since biliary obstruction to some extent must exist, it is
remarkable that jaundice does not appear to occur. In some cases attacks
of pain resembling in their character biliary colic, but without jaundice or
bilious urine, have been noticed. Ascites does not occur, and nothing further
is known as to the clinical results of this tuberculous lesion of the liver.

Primary Tuberculosis of the Biliary Tract. — As stress has been laid on the
bile ducts being secondarily involved in tuberculous disease of the liver, it
ought to be mentioned that Lancereaux has described a case of tuberculosis
of the common bile duct, gall-bladder, and cystic duct in a woman aged
thirty-two years, which he regards as directly due to infection from the
duodenum.

Local Tuberculosis not involving the Bile Ducts. Solitary Tubercle

Under the title solitary tubercle it will be convenient to describe caseous
tuberculous masses embedded in the liver substance without any connection
with the bile ducts. Masses of this kind are often met with in the livers of
animals, but are rare in man.

The fact that the masses do not open into the bile ducts suggests the
probability that the tubercles have arisen in the substance of the liver as
the result of bacilli conveyed to the liver by the hepatic artery, — much
in the same way as tuberculous foci are started in bone, — and that the
tubercle bacilli are not carried to the liver by the portal vein as in tuber-
culous pericholangitis, where the morbid process occupies the portal canals.

The recorded cases are curiously few. Moore in a recent paper only admits
five ; and of these two cases were of peculiar interest, in that in both caseous
masses were found in the livers of patients dying of carcinoma of the
pylorus. In both these cases the hepatic lesions resembled tubercle micro-
scopically except in the absence of tubercle bacilli. It was thought that the
absence of acid in the gastric juice had favoured the absorption of tubercle
bacilli through the ulcerated surface of the stomach. As no tubercle bacilli
were found, the possibility arises whether the caseous masses may not have
been due to the activity of the pseudo-tuberculosis bacillus described by A.
Pfeiffer and by Klein. Klein has recently shown that this bacillus,
obtained from the water of the rivers Thames and Lee, produces caseous
masses in the liver, lungs, and lymphatic glands of animals. It is, there-
fore, possible that some of these solitary caseous masses are not tuberculous.

My own belief is that solitary tuberculous masses are not nearly so rare
as the recorded instances would suggest ; I have seen at least two myself.
These localised caseous masses of tubercle must be carefully distinguished
from gummata, and are hardly likely to be imitated by actinomycosis.

Sometimes these solitary masses may soften down and form abscesses,
and may then set up localised suppuration in the neighbourhood of the liver.
In rare instances, as in a case related by Dr. T. L. Anderson, where there
was a mass the size of a tangerine orange in the left lobe of the liver, they
may be readily felt through the abdominal wall.

LIVEK, DISEASES OF 537

The diagnosis of these caseous masses is usually impossible; if these
nodules are felt in the liver of a patient with tubercle elsewhere their true
nature might be suspected. If they softened down and presented as a
fluctuating swelling, the signs would be indistinguishable from those of an
ordinary abscess.

LITERATURE.— Anderson. The Australasian Medical Gazette, 1899, p. 93.— Fletcher,
H. M. Trans. Path. Soc. vol. 1. p. 160.— Klein. Lancet, 1899, vol. ii. p. 1297.— Kotlar.
Zeitschrift. f. Heilkundc, Bd. xv. S. 121 ; 1894.— Lancereaux. TraiU des maladies dufoie et
du pancreas, p. 662; 1899.— Moore, F. C. Medical Chronicle, Oct. 1899.— Sargent. These.
Paris, 1895. — Simmonds. Centralblatt f. Path. Bd. ix. S. 865.

Syphilis of the Liver
Acquired Syphilis . . 537 [ Hereditary Syphilis . . 542

Acquired Syphilis

Secondary Manifestations. — In the secondary stage of acquired syphilis
jaundice is occasionally seen at the same time as the roseola ; it appears to
be due to the syphilitic infection, for it is amenable to mercurial treatment,
and if untreated, does not pass off in the way that an accidental or inter-
current catarrhal jaundice would do. It is benign, and must be distinguished
from the jaundice of icterus gravis, which sometimes supervenes in the
secondary stage of syphilis. As to the cause of this jaundice there is con-
siderable doubt ; it has been variously suggested that it is due to an eruption
on the mucous membrane of the bile ducts corresponding to that of the skin,
to enlarged glands in the portal fissure, or to a generalised toxic disturbance
of the liver, which may or may not lead to the generalised intercellular
cirrhosis characteristic of the congenital form of the disease.

It is generally believed that diffuse pericellular cirrhosis is peculiar to
congenital syphilis, and that it does not occur in the acquired disease.
This is probably too absolute a statement, and its accuracy may well be
questioned. It is true that it is very seldom seen, partly because the liver
is less often affected in acquired syphilis than in the hereditary disease,
and partly because opportunities for examining the liver during the
secondary period only occur in rare and accidental instances. A diffuse
pericellular cirrhosis is certainly present in some instances of acquired
syphilis, even without any gummatous change, and is constantly seen
around gummata that are not very old.

To sum up, in the secondary stage the liver may be so_ affected as to
give rise to jaundice. This is rare, the jaundice is usually benign, but it may
be due to acute degenerative changes supervening in the cells of a liver
already affected, and its resistance impaired, by the baneful influence of the
syphilitic toxin. Further, it is probable that a diffuse pericellular cirrhosis
like that seen in congenital syphilis does occur; but apart from the
possibility that it may in part be responsible for icterus, no clinical
symptoms can be correlated with it.

The Tertiary Manifestations of Syphilis in the Liver. — 1. Lar-
daceous Disease.— Since the advent of antiseptic surgery prolonged suppura-
tion has become so comparatively infrequent that syphilis is now re-
sponsible for a much larger proportion of the cases of lardaceous disease.
The subject is considered elsewhere. ( Vide " Lardaceous Disease.")

Here it may, however, be pointed out that lardaceous disease may
co-exist with gummata and cicatrices in the liver, and may thus lead to

538 LIVEE, DISEASES OF

increase in size of the organ. Occasionally the lardaceous change is limited
to an area around a gumma, thus suggesting its dependence on a toxin
whose action is concentrated in and near the gumma.

Gummata and Cicatrices. — The liver is more often affected by these
lesions than any other abdominal viscus. Their characters are so well
known that there is rather a tendency to regard them as commoner than
they actually are. Dr. J. L. Allen at my suggestion critically examined
the post-mortem records of St. George's Hospital for forty-two years
(1857-1898), during which period 11,629 autopsies were performed; he
found thirty -seven cases of undoubted gummata, and twenty -seven
additional cases in which cicatrices were present. There is, therefore, a
contrast between the frequency of hepatic lesions in hereditary and its
incidence in acquired syphilis.

Disposing Conditions. — Men are more often affected than women. Thus
in a collection of eighty-three cases, sixty were males, and twenty-three
females (Allen). It has been thought that any factor such as traumatism,
alcoholism, malaria, or a past attack of jaundice, that would diminish the
vital resistance of the liver, would render the organ more prone to
gummatous disease.

The greater frequency of gummata on the anterior surface of the liver,
which is more exposed to blows, the fact that gummata are not infre-
quently found close to the falciform ligament, where strain from falls must
tell, and the increased incidence in the male sex, though this may be merely
due to their being more often syphilitic, are points in favour of traumatism
playing a part in the localization of tertiary syphilitic lesions in the liver.

It is reasonable to believe that alcohol being a protoplasmic poison,
syphilitic lesions would be commoner in the livers of the drunken than in
temperate persons suffering from syphilis. It is curious, however, to note
how seldom cirrhosis and gummata are found in the same liver.

Morbid Anatomy. — In its earliest stage the future gumma is a mass of
syphilitic granulation tissue or a syphiloma ; it is of a pink-gray colour, and
does not show any central necrosis. As a result of impaired blood-supply
depending on syphilitic endarteritis of the vessels, and probably also from
an increase in the amount of the syphilitic toxin, the cells in the centre of
the syphiloma die and undergo caseation. The term gumma or gummy
tumour is now applicable, the caseous contents when softened having some
resemblance to gum. In the caseous material crystals of cholesterin and
stearic acid and granules of fat may be seen. In stained sections the caseous
area has a homogeneous appearance, and takes the dye badly or not at all.

Near the caseous material giant cells are sometimes seen, their function
is to absorb the debris ; they are absent in old gummata, and are rarely so
well developed or so numerous as in tuberculous formations.

The granulation tissue surrounding the caseous debris undergoes
organisation, and forms a fibrous capsule around it, in which there may be
found fresh elastic fibres. Spreading out from this into the liver tissue
are seen small cell infiltration (intercellular cirrhosis) and bands of fibrous
tissue, while the arteries enclosed in the capsule of the gumma show pro-
liferation of the intima and narrowing of their lumen (endarteritis obliterans).
In the immediate neighbourhood of the fibrous capsule pseudo-bile canali-
culi are often seen, while the liver cells are flattened and pressed out of
shape. There are thus three zones in a gumma : (1) The central caseous
material. (2) The fibrous capsule. (3) The extension of inflammation
into the surrounding liver tissue.

In young gummata the fibrous capsule is indefinite, and there is ex-

LIVER, DISEASES OF 539

tensive infiltration of the surrounding tissues, which may spread to the
capsule of the liver, setting up perihepatitis and adhesions, and even in-
filtrate the diaphragm or the abdominal wall. In an old gumma there is
little intercellular cirrhosis around it, the fibrous capsule is thick and is
contracting on its caseous contents ; these may gradually undergo absorp-
tion, and a scar is left. When undergoing absorption as the result of
treatment with iodides, gummata may soften down ; but this may also be
due to secondary infection, and such a gumma may resemble a chronic
abscess and even open into a bile duct.

Calcification of a gumma sometimes occurs, either of the caseous centre
or of its capsule. A remarkable case of diffuse calcification of the liver
recorded by Targett was probably secondary to gummatous infiltration.

Cicatrices are generally regarded as the remains of old gummata which
have contracted up and undergone absorption ; but it is probable that they
may develop from masses of syphilitic granulation tissue without any
preliminary necrosis and caseation. They are seen on the surface of
the organ, especially on its convexity, as white depressions invading the
substance of the organ for a short distance, being often conical in shape
and tapering towards the interior of the liver.

Situation and Results. — Gummata are usually multiple, though one may
be much bigger than the rest; in eighty-six cases of hepatic gummata
collected by Dr. Allen only eleven were single. They are much commoner
on the anterior surface of the liver than elsewhere, and are said, though this
is not my experience, to be specially apt to occur near the falciform liga-
ment. They are very rarely seen embedded in the substance of the organ
away from the surface. They are more often met with in the right than in
the left lobe. On section they have a dead white colour, and sometimes
closely resemble secondary carcinomatous masses.

In well-marked cases the liver is much deformed from the contraction
that gummata and their cicatrices induce, and its surface may be depressed
and furrowed so as to resemble the lobulation of foetal kidneys. A com-
bination of gummata and cicatrices may indeed practically destroy a part
or the whole of a lobe ; usually, however, gummata and cicatrices are cir-
cumscribed, and the intervening liver tissue is healthy, thus contrasting
with the diffuse pericellular cirrhosis of congenital syphilis. They often set
up local chronic perihepatitis — very rarely universal chronic perihepatitis.
When combined with lardaceous disease a gummatous liver is larger ;than
natural, as a rule it is about the normal size, and where greatly deformed
may be smaller than natural.

Signs and Symptoms. — Gummata and cicatrices are frequently latent
and give rise to no disturbance during life. The factors that determine
the development of symptoms are : (1) their size and extent ; (2) their
position.

(1) If a gumma is large it will give rise to the signs of a tumour, and
by irritating the capsule of the liver to perihepatitis and pain, while the
morbid metabolism going on inside it may lead to the production and
absorption of poisons which will lead to constitutional symptoms, such as
anaemia, asthenia, and perhaps fever.

(2) A cicatrix or small gumma on the convexity of the liver need give
rise to no symptoms, but if situated in the portal fissure jaundice and ascites
may follow.

There is a great difference between the relative importance of a caseous
gumma and an old cicatrix; for symptoms due to the pressure of an
adjacent caseous gumma may be relieved, or disappear under the influence

540 LIVER, DISEASES OF

of iodide of potash, whereas it is highly improbable that an old cicatrix
will be altered by such treatment.

Onset. — A fair proportion of the cases manifest themselves within three
years of the primary infection, sometimes hepatic manifestations occur
much earlier and with great rapidity. On the other hand, a long interval
may occur between the infection and the appearance of any symptoms ; they
may be postponed for thirty or forty years, so that, as in tuberculosis, it
might be said that no man should be regarded as cured of syphilis until his
autopsy had been thoroughly performed.

The clinical manifestations of the tertiary syphilitic lesions of the liver
may be present themselves under the following aspects : —

(1) Eesembling common cirrhosis and simple chronic peritonitis and
perihepatitis.

(2) Presenting the features of lardaceous disease, with albuminuria,
oedema, and perhaps diarrhoea.

(3) Eesembling tumour of the liver or of the neighbouring parts.

(4) Suggesting hepatic abscess.

(1) If a gumma presses on the portal vein or its branches the symptoms
of portal obstruction — hsematemesis, dilated abdominal veins, ascites,
asthenia, wasting, etc. — will follow.

These are the cases that recover under iodide of potassium, and probably
account for some of the reputed cures of common cirrhosis. If the gumma
is large absorption may be imperfect, and a cicatrix will be left behind
which may permanently compress the portal vein and bile duct in the
hilum of the liver and not yield to antisyphilitic treatment. These cases
then closely resemble cirrhosis in the symptoms. Jaundice is a rare event
in syphilitic disease of the liver, ascites is much more frequent.

The presence of gummata on the surface of the liver sets up local
perihepatitis, and thus gives rise to discomfort, dragging, and even pain in
the hepatic region which may radiate up to the right shoulder. The peri-
hepatitis is very seldom universal ; when this is the case it may account
for ascites ; ascites may also be due to extension of the chronic inflamma-
tion to the peritoneum, while a rare cause is narrowing and stricture of the
hepatic veins by gummatous infiltration, or the contraction of cicatrices
near their opening into the inferior vena cava.

Diagnosis from Cirrhosis. — A history of infection and manifest signs of
syphilis are indications for active antisyphilitic treatment that should never
be neglected. If it is palpable, the syphilitic liver will probably be felt to
be irregular, and if enlarged the increase in size is not uniform, or shared
in by the left lobe as it is in large cirrhotic livers.

Enlargement of the spleen in the absence of lardaceous disease, which
itself suggests syphilis, points to cirrhosis. An alcoholic history and long-
continued dyspepsia are also in favour of cirrhosis.

Diagnosis from simple Chronic Peritonitis and Perihepatitis. — Cases of
syphilitic disease of the liver in which ascites recurs will closely resemble
cases of simple chronic peritonitis, of which chronic universal perihepatitis
is only a part.

Chronic and recurrent ascites only occurs in a small proportion of the
cases of syphilitic disease of the liver, while it is constant in cases of simple
peritonitis and perihepatitis. In order, therefore, to regard a case of recur-
rent ascites as due to syphilitic disease of the liver, there must be undoubted
evidence of syphilis in the body, and of enlargement and irregularities on
the surface of the liver, such as would be produced by gummata and not by
chronic perihepatitis.

LIVER, DISEASES OF 541

Treatment by iodides, if successful in a doubtful case, would point to
syphilis.

(2) When gummata in the liver are associated with widespread lar-
daceous disease, the albuminuria and oedema of the legs may render the
aspect of the case that of lardaceous disease, and no symptoms may be found
suggesting gummata in the liver.

(3) Gummata imitating Hepatic Tumours. — When, as they usually are,
gummata are situated on the anterior surface of the liver, the irregularities
they give rise to may be readily felt through the abdominal wall. The
elevations of the liver substance due to the contraction of cicatrices are also
easily palpable. These nodules, however, are not umbilicated as the
secondary carcinomatous nodules are. But no stress can be laid on umbili-
cation, for it may be felt over a gumma projecting from the surface of the
liver.

When gummata are associated with lardaceous change in the same liver
the enlargement may be very considerable, and the resemblance to carcinoma
very considerable. The irregularities produced by cicatrices in a lardaceous
liver have a similar resemblance to malignant disease. In such cases
albuminuria points to lardaceous disease, and is therefore in favour of
syphilis. Jaundice and ascites, especially together, are more likely to be
met with in malignant disease ; other points in favour of growth are rapid
increase in the size of the liver, marked constitutional symptoms, and, of
course, any signs of a growth elsewhere. In a syphilitic subject enlarge-
ment and irregularity of the liver may be due either to gummatous disease or
to new growth, for syphilis, of course, in no way protects against malignant
disease. The vigorous administration of iodides and mercury should decide
the question, diminution in size of the liver settling the diagnosis in favour
of gumma.

Difficulty sometimes arises in deciding between gummatous infiltration
of a lobe of the liver and a hydatid cyst covered over by a layer of liver sub-
stance. The general health in hydatid is unaffected unless suppuration has
occurred, and the liver is smooth, whereas in syphilis other signs of the
disease and irregularity of the liver should be present. In any doubtful
case iodides should be given at once.

It can very rarely happen that a gumma imitates a distended gall-
bladder, but this has occurred.

(4) Occasionally an irregular or hectic temperature accompanies gum-
matous change in the liver, and might suggest ordinary suppuration, malaria,
tuberculosis, or even typhoid fever : it usually yields to iodides.

As a result of secondary infection a gumma may soften down, and may
present as a fluctuating swelling either anteriorly or by perforating through
the intercostal spaces laterally or posteriorly.

Prognosis. — When adequately treated with iodides the prognosis of
syphilitic disease of the liver is much better than in most of the conditions
that have been referred to as sometimes resembling it, viz. malignant
disease, cirrhosis, perihepatitis, and chronic peritonitis.

Gummata undergo absorption, and the bad effects due to their mechanical
pressure are relieved; but cicatrices are left behind, and if they compress
the portal vein or bile ducts the symptoms will remain practically unaffected.
Antisyphilitic treatment does not affect them, so it is not fair to assume
that the failure of iodides proves the condition to be non-syphilitic.

The prognosis of hepatic enlargement or tumour due to syphilis is thus
much brighter than that of ascites or jaundice thought to depend on some
other factor.

542 LIVEE, DISEASES OF

Treatment. — Iodides should be given in combination with mercury.
Iodide of potassium should be combined with iodide of sodium, and with
an ammonium salt such as spiritus ammoniae aromaticus, so as to prevent
the depressing effect of the potash. To begin with, a dose containing 10
grains of the combined iodides should be given three times daily, and should
be increased so that in a fortnight's time 30 grains are taken for a dose.
The medicine should be taken shortly before meals ; if taken on a full
stomach dyspepsia may result from liberation of iodine by the action of the
hydrochloric acid of the gastric juice.

Mercury may be given in the form of hydrargyri c. creta combined with
compound ipecacuanha powder to prevent diarrhoea.

In cases where gummata develop rapidly and early after infection, the
subcutaneous or better intra-muscular injection of soluble mercurial salts,
such as the benzoate, should be employed.

The Surgical Treatment of Gummata. — In cases where a softened gumma
of the liver has begun to work its way out through the abdominal wall, in-
cision and removal of some of the caseous debris has had a good result in
diminishing septic absorption. In other cases in which exploratory laparo-
tomy revealed an hepatic gumma partial removal has seemed to accelerate
the subsequent action of iodides.

It is not likely to be employed except in the event of a gumma simulat-
ing an abscess, or where the diagnosis has been at fault.

LITERATURE. — Adami. Montreal Medical Journ. June 1898. — Targett. Trans. Path.
Soc. vol. xl. p. 123. — Wilks. Trans. Path. Soc. vol. viii. p. 240. — Gay's Hospital Reports,
vol. ix.

Hereditary Syphilis

The changes in the liver that depend on hereditary syphilis may con-
veniently be considered under three heads : —

(i.) The lesions met with in the livers of babies, manifesting the other
ordinary evidences of hereditary syphilis.

(ii.) Tardive or delayed hereditary syphilis.

(hi.) Multilobular cirrhosis supervening in children, the subjects of
hereditary syphilitic infection.

The first of these categories is the most important, and refers to the
lesions ordinarily known as the liver of congenital syphilis.

The Ordinary Hepatic Manifestations of Congenital Syphilis. — The liver
is found to be affected in a very large proportion of the fatal cases of
hereditary syphilis ; this contrasts with acquired syphilis, where the liver
frequently escapes. The frequency with which the liver is affected in
hereditary syphilis is an argument in favour of the view that ante-natal
infection of the foetus is maternal, and that the infection passes through the
placenta and umbilical vein, thus damaging the liver on its way to the foetus.
If the ovum was primarily infected by a syphilised spermatozoon the ovum
would probably not survive ; and further, if it did, the syphilitic toxin
would reach the liver, as it does in acquired infection by the hepatic artery,
and should therefore only be affected in the same proportion as in acquired
syphilis.

Morbid Anatomy. — The appearances vary very considerably. In slight
cases the organ may show little change except some pallor. In other cases
its colour may be brown, yellowish, or violet, and may in advanced cases
look like flint. To livers of this type Gubler applied the term "foie silex."

The organ is enlarged and heavier than normally, weighing TVth to TVtb

LIVER, DISEASES OF 54:;

instead of -^g-th of the normal body weight at birth. Evidence of past peri-
hepatitis in adhesions to the diaphragm are sometimes seen, but usually
the surface is smooth, though there may be irregularities and projections
due to the changes being more advanced in certain areas of the liver.

On section the liver tissue is firm and tough, and appears marbled or
mottled from the presence of pale, whitish -yellow areas, where there is
increased fibrosis, with congestion around them. The lobular markings are
obscured or lost, and the appearances may suggest lardaceous disease or
diffuse sarcoma.

As a rule the changes are diffuse, and thus contrast with the circum-
scribed lesions of tertiary acquired syphilis ; but exceptionally the change
may be so localised as to imitate a tumour.

On carefully looking at the cut section small millet seed nodules re-
sembling tubercules are often detected. These are minute syphilomata,
composed of granulation tissue, and have been spoken of as miliary gum-
mata, though the term gumma is better reserved for the further stage where
central necrosis and caseation has supervened.

In rare instances well-marked gummata, comparable to those met with
in acquired syphilis, are found in the liver of infants, or even in still-born
foetuses.

Another and a rare appearance is a localised fibrosis of part of a lobe ;
this may indeed imitate a tumour, and cases described as fibroma of the
liver are probably of this nature.

Histologically. — The essential change is that seen in the secondary stage
of syphilis, viz. a diffuse small cell infiltration. The individual liver cells
are separated from each other by young connective tissue, the result of pro-
liferation (a) of the pre-existing connective tissue cells of the organ ; (b) of
the endothelium of the capillaries and lymphatics in the lobule of the liver ;
Kupffer's star-like cells, which are intimately connected with the endothelial
lining of the vessel walls, share in this change. According to the duration
and activity of the process there may be small round cells, spindle cells, or
fairly well-formed fibrous tissue. This diffuse fibrosis is variously spoken of
as a monocellular, unicellular, intercellular, or pericellular cirrhosis. When
the process is seen in an early stage the small round cells may suggest
sarcoma ; when a number of these cells are collected together a syphilitic
granuloma or miliary gumma is formed.

The liver -cells are compressed, shrunken, granular, and sometimes
undergo necrosis and disappear. They do not undergo fatty change.
When compressed they may appear in rows like the so-called new bile
ducts.

The fibrous tissue of the portal canals is increased in amount. The
hepatic artery is normal, and although in exceptional instances changes in
the branches of the portal vein and bile ducts have been described, they are,
practically speaking, always healthy.

In different stages of the disease the appearances vary, thus pericellular
cirrhosis alone, combined with miliary syphilomata, with fibrous tissue, and
even with well-defined gummata, may be found.

The diffuse monocellular cirrhosis is like the secondary lesions elsewhere
in the body, a curable condition if treated by mercury, but it may pass
into the tertiary manifestations and lead to gummata, cicatrices, diffuse
fibrosis, and lardaceous disease.

Clinical Features. — As a rule symptoms pointing to the liver are entirely
absent, the ordinary signs of congenital syphilis are found with enlargement
of the liver and spleen.

544 LIVEE, DISEASES OF

The liver is smooth, firm, and tender ; in exceptional instances part of it
may be so prominent as to feel like a tumour.

Jaundice is rare, it is like the jaundice occasionally seen in the secondary
stage of acquired syphilis, and may be referred to one of the following
causes : enlarged glands in the portal fissure exerting pressure on the ducts,
inflammation of the small ducts, and intime changes in the liver cells and
minute bile ducts. In some of the cases the jaundice is terminal and due
to secondary infections falling on the liver, a form of icterus gravis.

Ascites is rarely seen except in stillborn children. It may be due to
peritonitis, which, as shown by perihepatic adhesions, may occur in this
disease.

The hepatic enlargement corresponds to the other manifestations of the
disease, and hence may be taken as an index of the severity of the infec-
tion. In some cases the liver may reach down as far as the crest of the
ilium. In connection with this it should be borne in mind that the liver is
not only relatively larger in infants than in adults, but that it normally
projects farther down below the ribs, so that slight apparent enlargement
of the liver is not of any importance.

Treatment is that of congenital syphilis by mercury either by inunction
or by the mouth. Mercurial ointment should be rubbed into the skin of
the axillse, groins, etc., with flannel ; a different area of skin should be em-
ployed from day to day. The method of inunction is more rapid in its
action and less likely to lead to salivation than the administration of mer-
cury by the mouth. It should be practised daily for three months, after
that it should be dropped for a week at a time at first, and then for two
weeks. In the second year of treatment inunction should be practised for
one month out of every three, and small doses of iodide of potassium given ;
this should be continued in the third year, the iodide being increased ; in
the fourth year the mercurial treatment should be stopped, but the iodide
should be continued. By these means the development of tertiary mani-
festations should be presented.

When mercury is given by the mouth it is usually administered in the
form of hydrargyr. c. creta ; to an infant under two months old ^ gr. should
be given twice a day, the dose being increased to one grain after a time.

Hepatic Lesions of delayed or tardive Hereditary Syphilis. — Here hepatic
manifestations develop very much later than in the last category, often
coming on about puberty or even in adult life. The lesions are tertiary in
character and resemble those seen in the acquired form of the disease.
"What has happened is that the hepatic lesions characteristic of hereditary
syphilis (pericellular cirrhosis) have persisted, and instead of being cured
by treatment have passed on into the tertiary stage.

Since the lesions are the same as those of the tertiary stage of acquired
syphilis, there must be some other evidence of the hereditary form, such as
interstitial keratitis or Hutchinson's teeth, in order to be certain that the
case is one of delayed hereditary syphilis, otherwise the disease might have
been acquired in early life, for example from a wet nurse.

The liver may be greatly deformed from contracting cicatrices, and may
be divided up into numerous lobules, in fact some of the recorded examples
of abnormal lobulation of the liver are of this nature. In some cases there
may be extensive lardaceous disease, giving rise to albuminuria, diarrhoea,
and enlargement of the spleen. The pressure of a gumma or contraction
of its cicatrix may involve the portal vein or more rarely the bile duct,
giving rise to ascites and jaundice.

From cirrhosis of the liver and new growths this condition may be

LIVEE, DISEASES OF 545

distinguished by the presence of syphilitic lesions in the skin, bones, and
sense organs, eye, nose, ear ; and by the effect of antisyphilitic remedies.

From acquired syphilis it is distinguished by the presence of stigmata
of the congenital form, such as nebuloe on the cornea from former inter-
stitial keratitis, or Hutchinson's teeth.

The clinical characters and treatment are the same as those of the
acquired disease.

Multilobular Cirrhosis developing in the Subjects of Hereditary Syphilis. —
The diffuse pericellular cirrhosis of infants the subject of congenital syphilis
is, like the lesions of the secondary stage of the acquired disease, a curable
lesion. Microscopic examination of the livers of children formerly affected
with well-marked hereditary syphilis may show no disease. On the other
hand, every now and again the liver of a child who bears undoubted stig-
mata of congenital syphilis in the body is found to show ordinary cirrhosis.
The arrangement of the two lesions is so dissimilar that pericellular cirrhosis
cannot be thought to be transformed into multilobular cirrhosis ; it would
rather tend to diffuse fibrosis or gummatous change. It seems probable
that the pericellular cirrhosis undergoes absorption, but that some vulner-
ability and diminished resistance of the liver is left behind. If causes then
arise that tend to produce ordinary cirrhosis this change will be readily pro-
duced. In other words, the multilobular cirrhosis is a parasyphilitic lesion,
and is comparable to general paralysis of the insane, in that though not
syphilitic it is favoured by syphilisation of the soil.

In some instances there is very diffuse cirrhosis, suggesting that multi-
lobular cirrhosis has supervened before the pericellular cirrhosis had receded,
and that some of the fibrous infiltration was due to organisation of the
pericellular formation.

Occasionally in multilobular cirrhosis occurring early in life in the
subjects of congenital syphilis there is early lardaceous change in the organ.

What proportion of small cirrhotic livers in children have a substratum
of syphilitic taint it is difficult to say. Statistics of reported cases of
cirrhosis in children make it clear that direct evidence of syphilis is often
not forthcoming.

The clinical features of these cases of cirrhosis is much the same as
those of common (small liver) cirrhosis, viz. those of portal obstruction,
ascites, wasting, etc.

It may be very difficult to differentiate between these cases of cirrhosis
in individuals with other manifest signs of congenital syphilis on the one
hand, and cases of tardive hereditary syphilis with hepatic lesions and
ascites on the other hand. In the latter there may be excessive lardaceous
disease as shown by albuminuria. Iodide of potassium and mercury should
be tried, and improvement will point to hepatic gummata and cicatrices
clue to tardive hereditary syphilis, and must then be pushed.

The prognosis of these cases is very bad.

The treatment is that of ordinary cirrhosis, viz. milk diet, no alcohol
or irritating food. The prevention of constipation and auto-intoxication by
intestinal antiseptics such as calomel, salicylate of soda, /5-naphthol, is
important.

Iodide of potassium should be given constantly, as is often done in
common cirrhosis of adults, to prevent if possible any further progress in
the disease. But as the lesion is parasyphilitic rather than syphilitic,
iodide of potassium can hardly be expected to remove the fibrosis.

LITERATURE.— Hereditary syphilis : Adami. Montreal Med. Journ. June 1898. —
Fletcher, Morley. Trans. Path. Soc. vol. 1. p. 138!— Gubler. Gaz. mid. Paris, 1852, p.

vol. vi 35

546 LIVEE, DISEASES OE

262. — Hittinel et Hudelo. Archiv. de experiment, mid. Paris, 1890, p. 509. — Marchand.
Centralblatt f. allg. Path. 1896_, Bd. vii. S. 273.— Wilks. Trans. Path. Soc. vol. xvii. p.
167. Tardive hereditary syphilis : Fournier. Syphilis hdreditaire tardive, 1896. — Morris,
H. Trans. Path. Soc. vol. xxxi. p. 214. — Plicque. Gaz. des hop. Paris, Jan. 8, 1898. —
Post. Boston City Hosp. Report, 1898, p. 233.— Tzeytlin. These, Paris, 1896.— Wilks,
S. Guy's Hospital Reports, vol. ix. p. 24, 1863.— Parasyphilitic multilobular cirrhosis:
Payne. Brit. Med. Joum. 1899, vol. ii. p. 1604. — Rolleston. Clinical Journal, Sept. 9,
1896.

Lymphadenoma

In generalised lymphadenoma the liver not infrequently contains
nodules of growth. As a rule they are small, and rarely give rise to much
enlargement of the organ.

In exceptional cases the liver is considerably enlarged, and if the super-
ficial lymphatic glands available for clinical examination are little affected,
the clinical aspect may suggest hepatic abscess as in a case under my care,
or even malignant disease of the liver (Suchard et Teissier). For the morbid
anatomy and other details vide article on " Lymphadenoma."

LITERATURE.— Suchard et Teissier. Bull. soc. anat. 1897, p. 940.

Actinomycosis of the Liver

When actinomycosis occurs in the liver it must always be conveyed
from some absorbent surface, such as the intestines, or spread to the liver
by continuity. In thirty cases of hepatic actinomycosis collected by
Aribaud, the growth was derived from the alimentary tract in twenty,
spreading by direct extension in eight cases, and by metastasis in twelve.
The liver may be affected by extension from the base of the lung, the
infection spreading through the diaphragm, or possibly the primary lesion
may be in the skin of the abdominal wall.

Sometimes the primary source of inlet is not found; thus Taylor, Shattock,
and Boari have described primary actinomycosis of the liver.

Morbid Anatomy. — The liver is enlarged. The actinomycotic abscess has
a characteristic honeycombed aspect, and has been compared to a sponge
soaked in pus. The alveolar appearance is due to the coalescence of a number
of small abscesses. The suppurative process spreads by continuity, and is
accordingly more or less localised, but sometimes small abscesses are seen
away from the main collection. The abscesses vary in size from a pin's head
to that of a walnut, the pus contains the characteristic granules composed of
the ray fungus — or actinomyces colonies — and numerous pyogenetic micro-
organisms. Around the areas of suppuration there is fibrosis with pig-
mentation of the walls of the small abscesses. The remainder of the liver
may be congested and fatty. Microscopically there is intercellular cirrhosis
in the immediate neighbourhood, with atrophy of the liver-cells.

Eor the nature and characters of the fungus the reader is referred 10
Professor Delepine's article, vol. i. p. 71.

There is a great tendency to get inflammation of the capsule of the
liver and adhesions to adjacent organs. If the actinomycotic lesion is
situated anteriorly it readily extends to the abdominal wall, and may lead
to an abscess. This may be the first evidence of disease, so that caution is
required in assuming that the hepatic lesion is secondary to an abscess of
the abdominal wall.

The actinomycotic abscess may spread through the diaphragm to the
pleura or into the lung, and may first appear as an empyema of chronic
character and obscure origin.

LIVER, DISEASES OF

>47

In rare cases (Israel, Kanthack) actinomycosis may be pysemic, and
spread by the blood-vessels. In Kanthack's case it was not clear whether
the abscess originated in the right lobe of the liver or at the base of the
right lung ; from this it had spread by continuity into the right suprarenal
body, and then given rise to secondary pysemic abscesses over the body.

In Boari's case there were secondary pysemic abscesses due to pyogenetic
cocci, and not containing actinomycosis.

Clinical Aspect. — The first evidence may be that of an empyema, of an
abscess in the abdominal wall, or, when the portion of the liver near the
kidney is involved, of a perinephritic abscess.

The liver may be enlarged, and with a slight degree of fever and some
pain over the liver the suspicion of an hepatic abscess may arise. Jaundice
is extremely rare.

Diagnosis depends on finding the fungus in the pus, either from the
liver or from a discharging abscess elsewhere. Before this has been done
the condition is hardly likely to be thought of, and recorded cases show that
the disease has been regarded as empyema, phthisis, sarcoma of the kidney
(Leith), perinephritic abscess, hepatic abscess, suppurating hydatid, or
gumma of the liver.

Latimer and Welch describe a case of actinomycosis of the liver com-
bined with myelogenous leukaemia.

The prognosis depends on the disease being recognised and vigorously
treated with iodide of potassium, and on freedom from secondary infection
with pyogenetic micro-organisms.

Treatment. — The effect of iodide of potassium, introduced by Thomassen,
in actinomycosis is extremely marked, and does fully as much good as it
does in tertiary syphilis. It should be given in large doses — as much as a
drachm daily.

Locally iodoform may be employed and antiseptics to minimise septic
infection.

LITERATURE. — Aribaud. Quoted by Ruhrah, loc. cit. — Boari. 11 Policlinico, 1897,
No. 1, p. 19. — Kanthack. Trans. Path. Soc. vol. xlv. p. 233. — Latimer and Welch.
Trans. Assoc. American Physicians, 1896, p. 328. — Leith. Edinburgh Hospital Reports, vol.
ii. p. 121 ; 1894. — Ruhrah. Annals of Surgery, Oct. and Nov. 1899. — Shattock. Trans.
Path. Soc. vol. xxxvi. p. 254. — Taylor, F. Guy's Hospital Reports, vol. xlviii. p. 311 ; 1891.

Malignant Disease of the Liver

Malignant disease may be primary in the liver, but more commonly new
growth in the liver is secondary to a growth elsewhere. It will be con-
venient to consider the subject under these two heads :—

Primary Malignant Disease op.
the Liver —

Etiology .... 547

Morbid Anatomy . . 548

Carcinoma . . . 548

Sarcoma . . .549
Physical Signs and Symp-
toms .... 549
Diagnosis .... 550
Treatment . . .551

Primary Malignant Disease of the Liver

Malignant disease when it occurs primarily in the liver most frequently
starts in the gall-bladder. This subject has already been described (vol. iv.
p. 68), and here primary disease of the liver itself will be considered.

Frequency. — Primary malignant disease of the liver is a rather rare
disease, and although clinically it is common to meet with cases where the
manifestations are those of malignant disease in the liver without any

548 LIVEE, DISEASES OF

definite evidence of a primary growth elsewhere, the majority will be found
to be secondary to a latent growth elsewhere.

The ratio of the incidence of primary to secondary malignant disease of
the liver has been stated to be as 1 to 20.

Sex. — It is commoner in men than in women, thus contrasting with
primary cancer of the gall-bladder, which is four times commoner in women.

Age. — It is met with in or after middle life, and seldom occurs under
the age of forty years. It may, however, occur in quite early life. I have
notes of twenty-nine cases of primary sarcoma in children under ten years
of age, and congenital examples have been described.

Nature. — Primary carcinoma is much more frequent than primary
sarcoma of the liver. Very considerable variation exists in the forms of
carcinoma and sarcoma met with in the liver.

Carcinoma may be —

(1) Massive, a large growth expanding the liver around it, the surface
of which is smooth, though secondary nodules may arise away from the
main mass. This form of growth may for a time imitate an abscess or
hydatid. Ascites, jaundice, and perihepatitis are rare.

It is usually a rapidly growing spheroidal-celled carcinoma derived from
the liver -cells, or from the cubical epithelium of the smaller bile ducts ;
exceptionally it is a columnar -celled carcinoma starting from one of the
larger intra-hepatic ducts. In a few instances giant multinuclear cells are
found. A carcinoma starting in the gall-bladder and completely replacing
it may at first sight be mistaken for a primary massive carcinoma of the
liver.

(2) Infiltrating Form. — The greater part or even the whole of the liver
may be uniformly saturated with carcinoma ; sometimes the growth is
slow, and a great quantity of fibrous tissue is formed, with the result that
the organ is hard, like a small atrophied liver, and not necessarily increased
in size. In other cases the liver is widely infiltrated with active growth,
and is much increased in size and weight. Histologically this form is
generally spheroidal-celled carcinoma.

(3) Nodular. — The appearance of the liver is like that seen in secondary
carcinoma, the chief difference being that there is no primary growth else-
where in the body. The tumours grow rapidly, are prone to degenerate,
and sometimes become hemorrhagic. Possibly some of these cases are, like
carcinoma of the inguinal lymphatic glands, in sweeps without primary
carcinoma of the scrotum, examples of what has been termed secondary
growths without any manifest primary focus. It is compatible with the
parasitic theory of cancer to suppose that the hypothetical parasite might,
once having gained an entrance through the alimentary canal, set up
multiple lesions in the liver.

Possibly some cases of primary nodular carcinoma are due to growths
arising in accessory suprarenal bodies that have become embedded in the
liver.

It may be that one of the multiple nodules of growth was primary,
and that the others are secondary, but have grown more rapidly and so
rivalled it in size.

These growths are usually spheroidal-celled, but may be columnar-
celled, or show a transition from the latter to the spheroidal type.

Just as anatomically, so clinically this form resembles secondary
carcinoma of liver, in the frequency with which perihepatitis, pain, jaundice,
and ascites are met with.

(4) The condition termed carcinoma with cirrhosis somewhat resembles

LIVER, DISEASES OF 549

the nodular form on the one hand, and cirrhosis with adenoma on the other.
It has been chiefly described in France ; Hanot and Gilbert say that it is
the form met with in more than one-third of the total number of the cases
of primary carcinoma of the liver. There are multiple growths associated
with cirrhosis of the liver ; it is supposed that the compensatory hyperplasia
of the liver-cells that gives rise to multiple adenoma passes on into a
malignant activity, and that carcinoma develops. This form is frequently
associated with thrombosis of the portal and hepatic veins, the growth
being said to invade the veins. Secondary growths in the portal lymphatic
glands or elsewhere are rare. When they do occur, no doubt can exist
about the nature of the change in the liver, but in their absence it seems to
me probable that many of the cases described as carcinoma with cirrhosis
are merely nodular cirrhosis, or cirrhosis with multiple adenoma (vide p. 529).

Histologically the carcinomatous structure is described as being
trabecular, and resembling the pseudo-bile canaliculi seen in so many
conditions where compensatory hypertrophy of the liver -cells is
required.

It is noteworthy that the symptoms of these cases correspond with
those of cirrhosis.

Secondary growths in primary carcinoma of the liver occur in the liver
itself, in the glands in the portal fissure, and sometimes in the lungs, but
the course of the primary disease is so rapid that secondary metastases
have not time to become of importance.

Gall-stones are rarely found in primary carcinoma of the liver itself.
This contrasts with primary carcinoma of the gall-bladder, where the
association is present in 95 per cent of the cases.

Primary sarcoma of the liver is much rarer than primary carcinoma.
It may occur, as already mentioned, in early life, but a caution should be
thrown out not to regard as sarcoma the lesions of congenital syphilis.

The following forms of primary sarcoma may be mentioned : —

(1) A massive tumour which may soften down and imitate an abscess
or a cyst.

(2) A diffuse infiltrating form, as seen in cases occurring in early life,
and in the rare cases, of which about ten are on record, of primary melanotic
sarcoma of the liver.

(3) A multiple form without any primary growth.

The growth may start from the general connective tissue of Glisson's
capsule, from the perivascular sheaths, from Kupffer's star cells, or from
the endothelium of the vessels.

The histological characters of the primary sarcomata met with include
small round -celled, spindle -celled, mixed and irregular -celled, angio-
sarcoma, and melanotic growths. Difficulty not infrequently arises in
deciding whether a primary hepatic tumour should be labelled carcinoma
or sarcoma ; this depends on the tendency of the sarcomatous growth to
spread along the capillaries, and so to assume an alveolar appearance.

Physical Signs of Peimary Malignant Disease. — The liver is nearly
always enlarged ; it may be smooth or nodular, but in either case it increases
progressively and often rapidly in size. The enlarged liver may displace
the diaphragm upwards, and give rise to dulness at the base of the right
lung ; sometimes it is further complicated by pleural effusion.

Ascites and jaundice are not so frequent as in secondary malignant
disease of the liver. Ascites is said to be present in about half the cases,
and not to be found in the massive form of primary carcinoma. Jaundice
very rarely shows itself in the massive form ; when present it is not of the

550 LIVEE, DISEASES OF

dark green or black colour seen in some instances of secondary malignant
disease.

The patient's facial aspect is usually that of grave disease, and wasting
occurs, but the progress of the disease is so acute as compared with that of
secondary malignant disease that emaciation has barely time to become
marked. The tumour growth may be so rapid that the body-weight
actually increases in spite of general loss of flesh. (Edema of the feet may
develop in the late stages. The temperature may be raised, and bacterial
infection of the liver or the bile ducts may take place, and thus exception-
ally rigors may be met with.

There may be albuminuria due to toxic substances in the circulation
reaching the kidneys and damaging the delicate epithelium covering the
glomerular tufts. When there is jaundice bile pigment will be found in
the urine.

The chief symptoms are loss of strength, loss of appetite, gastric
disturbance, and pain over the liver. Vomiting may be reflex in origin.
Pain and tenderness depend on stretching of the capsule, or on local peri-
hepatitis set up by the growth involving the capsule.

In the late period of the disease hepatic insufficiency may be developed,
the patient passes into a drowsy, semi-comatose state, and haemorrhages
may appear.

The course of the disease is more rapid than that of secondary malignant
disease, and few cases last more than four months ; sometimes the disease
may justify the adjective acute, and its duration may be counted in weeks
rather than months.

Diagnosis. — Under this head the diagnosis of malignant disease in the
liver substance, whether primary or secondary from other conditions, will
first be considered, and then the distinction between primary and secondary
and malignant disease will be referred to.

In a few instances of primary malignant disease of the liver the exist-
ence of hepatic disease is not even suspected, but this is exceptional, and
enlargement will usually be detected.

In the massive form, where the surface is smooth, it must be distinguished
from lardaceous disease ; in the latter, attention must be directed to the
history of past suppuration, or of syphilis, and to signs of lardaceous change
elsewhere. In the enlargement due to a deep-seated hydatid the patient's
general health and strength remain good, while in carcinoma his powers
rapidly fail.

Multilocular or alveolar hydatid has often been mistaken for malignant
disease, both clinically and even when found after death. It has not been
described as occurring in England, and it is rare anywhere ; in most cases
of the disease the spleen is enlarged, thus differing from malignant disease.

The large and tender liver of the terminal stage of mitral disease has
been known to resemble malignant disease, but the history of the case
and the signs of cardiac and circulatory disturbance should prevent any
mistake.

In rare instances the rapid growth of the tumour may give rise to
fluctuation, while the raised temperature that is not infrequently seen may
further increase the resemblance to various forms of intra-hepatic sup-
puration, such as abscess, pylephlebitis, cholangitis, etc. Sometimes an
exploratory incision is the only means of deciding the question. It may
indeed happen that secondary infection either of the growth or of the ducts
occurs, and that suppuration is thus superimposed on new growth.

From the large liver of hypertrophic biliary cirrhosis primary malignant

LIVEE, DISEASES OF 551

disease differs in its more rapid growth, in the absence of splenic enlarge-
ment, and in the character of the jaundice. In malignant disease it is
either absent or, if present, obstructive, so that no bile passes into the
bowel. In biliary cirrhosis jaundice is constantly present, but bile colours
the faeces. Hypertrophic biliary cirrhosis is met with much earlier in life
than malignant disease.

In the late stages of ordinary or portal cirrhosis, if there be ascites and
jaundice, the resemblance to cases of multiple nodular malignant disease of
the liver is considerable ; after paracentesis, the condition of the liver, com-
paratively small in cirrhosis, large or extremely nodular in new growth,
will generally render a definite decision possible.

A large gumma of the liver may be accompanied by considerable cachexia,
but should be recognised by the signs of syphilis elsewhere, and by the
effect of vigorous treatment with iodides.

Occasionally faecal accumulation in the transverse colon may imitate
malignant disease ; here the tumours may vary in position from time to
time, can be indented by pressure, are capable of removal by purgatives or
abdominal massage, and when a careful examination is made, if need be
under an anaesthetic, other masses can be made out in the course of the
colon.

A renal tumour may appear to be in connection with the liver, but a
bimanual examination should be sufficient to show that it bulges into the
loin, while the presence of bowel in front of the tumour points to its renal
origin.

Inflammatory thickening around the gall-bladder is often palpable as a
hard mass, and thus may give rise to physical signs resembling carcinoma.
The history of gall-stones, and the fact that the patient's general state is
not so grave as in carcinoma, are important points to bear in mind.

The diagnosis of primary from secondary malignant disease of the liver
is very difficult, inasmuch as, in perhaps as many as 50 per cent of
those cases of secondary malignant disease of the liver that give rise to
symptoms, the existence of a primary growth elsewhere cannot be satis-
factorily determined during life. When there is evidence of a growth in
situations, such as the stomach, colon, or pancreas, the malignant disease in
the liver is evidently secondary. But when the only clinical evidence is of
growth in the liver, it is very difficult to come to a satisfactory conclusion
as to whether it is primary or secondary. Multiple growths, and the
association of jaundice and ascites, are rather in favour of secondary malignant
disease, while rapid growth of the liver without marked emaciation points
to a primary growth. Deep jaundice is in favour of secondary growths.

Malignant disease of the gall-bladder is usually preceded by biliary
colic, and shows itself as a tumour in the region of the gall-bladder.

The prognosis is of course absolutely hopeless, except in those very rare
instances where the tumour has been completely removed by the surgeon.

Treatment. — In a few exceptional instances a primary malignant tumour
of the liver has been removed. In most cases, however, this is impracticable
from the extent of the tumour and the frequency with which secondary
growths are found in other parts of the liver.

Apart from this the treatment is merely palliative, and consists in
relieving symptoms as they arise. Vomiting should be met by ice, bismuth,
dilute hydrocyanic acid, etc. ; dyspepsia by carminatives, ascites by para-
centesis, and pain by the hypodermic injection of morphia.

A milk diet is most suitable, tea and coffee may be given, and stimulants
are usually necessary.

552

LIVEE, DISEASES OF

Secondary Malignant Disease of the Liver

Etiology
Morbid Anatomy

Site of Primary Groivth

Carcinoma .

Sarcoma

552
552
552
552
553

Clinical Features and Course 553

Diagnosis (vide Diagnosis of " Pri-
mary Malignant Disease ")

Treatment

554
554

Frequency. — The liver is the organ most frequently affected by secondary
malignant disease. Thus it is involved in half the total cases of malignant
disease, and in 3 per cent of all bodies examined after death (Hale White).
In a large number of the cases collected for statistical purposes secondary
growths in the liver have given rise to no sign during life. It appears that
malignant disease is becoming more frequent, especially in the abdomen.

Sex. — Secondary malignant disease is rather commoner in women, from
the frequency of malignant disease in the breast and internal organs of
generation, than in men.

Age. — It usually occurs after forty years of age.

Site of Primary Growth. — The primary growth is latent in a large
number, perhaps in half of the cases presenting evidence of secondary
malignant disease of the liver during life. The stomach and colon are the
most frequent sites of the primary growth, but fatal cases of carcinoma of
the breast are very frequently found to have secondary growths in the liver.
Other situations in which the primary growth may occur are the pancreas,
gall-bladder, oesophagus, uterus, kidney, and uveal tract.

Secondary growths are usually carcinomatous ; sarcoma is comparatively
infrequent. This is probably due to the fact that it only rarely occurs
primarily within the area drained by the portal vein. Secondary melanotic
sarcoma of the liver is a striking but rather uncommon form of growth ;
it is much more marked after melanotic sarcoma of the uveal tract than of
the skin.

Morbid Anatomy. — The secondary growths are usually multiple and
nodular, but sometimes, for example, when secondary to carcinoma of the
mamma or to sarcoma of the uveal tract, there may be diffuse infiltration
of the organ. The two forms may be found in the different parts of the
same liver. The growths are frequently found on the surface of the liver,
and are rarely present inside when absent externally.

Carcinomatous growths are white, yellow, bile-stained, or streaked with
blood, and when of some standing become cupped or umbilicated. This
depends partly on cicatricial contraction taking place in the older portions,
and in part on the more exuberant growth of the peripheral and more recent
portions.

The nodules on the surface of the liver may set up perihepatitis and
adhesions to adjacent parts, while exceptionally the growth may grow
directly into the diaphragm or abdominal parietes.

The growths may soften down, and occasionally may suppurate as the
result of infection. In secondary squamous-cellecl carcinoma cysts contain-
ing clear fluid have been seen.

All three forms of carcinoma — spheroidal, columnar, squamous-celled —
are met with, and not infrequently, when the secondary growths are increas-
ing rapidly, there is a transition from the columnar-celled to the spheroidal-
celled type.

Secondary colloid carcinoma may occur, and sometimes, like other forms
of carcinoma, colloid carcinoma may spread by continuity into the portal
fissure.

LIVEK, DISEASES OF 55:5

Secondary carcinoma and sarcoma both begin inside the capillaries of
the liver, and hence a sarcoma often has an alveolar arrangement.

Pressure on the bile ducts and branches of the hepatic veins gives rise to
local bile staining and chronic venous congestion of the liver substance.

Carcinoma may be spread directly into the liver substance, especially
from primary carcinoma of the gall-bladder. Carcinoma of the stomach
may grow directly into the liver, or pass up the lesser omentum to the portal
fissure, and incidentally compress the bile duct and portal vein.

Sarcomatous growths are very rarely umbilicated ; they are prone to be
more hemorrhagic than carcinomatous nodules, and, like them, may soften
down and form pseudo-cysts. As the result of hemorrhage taking place
into the growths the size of the liver may suddenly increase. Eupture of a
hemorrhagic nodule of growth may give rise to severe collapse from haemor-
rhage into the peritoneum.

Clinical Features. — The liver is enlarged and progressively increases in
size, the right lobe being more affected than the left. Its surface is irregu-
lar and nodular, and the projections may, if the abdominal wall be thin, be
felt to be cupped in the centre ; this is a point of importance in distinguish-
ing it from the hobnailed liver of cirrhosis. Outlying nodules of growth
may be felt at the umbilicus or along the line of the falciform ligament.
The liver may be both painful and tender, from stretching of its capsule
and local perihepatitis which may reveal itself to the stethoscope by a
friction sound. The pain may spread from the right hypochondrium to the
back, and be felt in the loins.

The spleen is not enlarged, hsematemesis does not occur, and enlargement
of the abdominal veins, if present, is due to obstruction to the inferior vena
cava, and is not seen chiefly around the umbilicus, as it would be in portal
vein obstruction.

The patient is emaciated, more so than in primary malignant disease
of the organ, both because he is suffering from new growth in at least two
situations, and because the course of secondary malignant disease of the
liver is more protracted. The patient progressively loses strength, and
gradually passes into a condition of cachexia. The cachexia may be accom-
panied by a certain amount of fever.

Gastric disturbance, nausea, vomiting, and loss of appetite, with marked
distaste for meat, are commonly seen. The bowels are usually confined,
very occasionally there is diarrhoea.

Jaundice and ascites occur in about half the cases, and may be met with
together. The jaundice may be catarrhal, but is often due to gross obstruc-
tion of the ducts in the portal fissure, and is then progressive, and becomes
of a dark green colour. Bile disappears from the faeces and is present in
the urine. Pruritus may be troublesome ; and from the development of
cholaemia, haemorrhages into the skin, and bleeding from the nose, gums, and
mucous surfaces may result.

The jaundice, which does not last sufficiently long to allow of the
development of xanthelasma, is more likely to occur when the primary
growth is near the liver, as in the gall-bladder or stomach, whence a direct
continuity of the growth may spread to the larger ducts.

The pressure of growth in the portal fissure on the ducts may extend to
the portal vein, and give rise to ascites. In some instances the portal vein
itself is not involved, and the ascites is due either to chronic peritonitis set
up by malignant infection of the peritoneum, or to widespread infiltration
of the liver with new growth obstructing the branches of the portal vein.

The ascitic fluid may be clear, bile-stained, or more rarely chyliform or

554

LIVEE, DISEASES OF

hemorrhagic. In melanotic sarcoma it has in rare instances been found to
be of a dark colour from the presence of the pigment melanin.

The urine may be lithatic and contain indican ; in secondary melanotic
sarcoma of the liver the urine sometimes darkens on standing, from the
presence of melanin. The pigment is usually passed in a colourless form —
melanogen — and when oxidised darkens. This can be rapidly demonstrated
by adding nitric acid, ferric chloride, or bichromate of potash. Occasionally
the urine is already dark when voided from the bladder. Urine containing
indican darkens with nitric acid, but not with perchloride of iron ; the
latter reaction is useful in distinguishing melanuria from indicanuria.

Albuminuria and glycosuria are very infrequent in secondary malignant
disease of the liver.

Termination. — Unless life is cut short by some complication, death
occurs from gradually increasing weakness passing into coma, which may be
extreme when the patient is jaundiced or suffering from cholsemia.

Duration. — After the liver is known to be involved, life is seldom pro-
longed for more than six months ; sometimes the course of the disease is
more rapid. Much depends on the position and nature of the primary
growth. If it be latent, have been removed, or, as in colotomy, be prevented
from setting up obstruction, life may be carried on for a year, or even more.
Sometimes the patient holds his own for a while and then rapidly goes
down hill.

The prognosis is of course quite hopeless. Operative interference
cannot be expected to do any good since the growths are multiple.

The diagnosis has already been discussed under the heading of primary
malignant disease.

The treatment — symptomatic and purely palliative — is in the main the
same as that of primary malignant disease. For pruritus due to marked
jaundice chloride of calcium may be given in full doses for a day or two
and then stopped. If this fails, pilocarpine | - \ gr. or morphia may be
given hypodermically. Alkaline baths or sponging the skin with carbolic
lotion 1 in 40 sometimes give relief.

LITERATURE. —Bramwell and Leith. (Sarcoma), Lancet, 1897, vol. i. p. 170.—
Delepine. (Melanotic Sarcoma), Trans. Path. Soc. vol. xliii. p. 61. — Hanot et Gilbert.
Etudes sur les maladies dufoie,l888. — Lancereatjx. Traite des maladies dufoie et du pancreas,
1899.— Rolleston. (Melanotic Sarcoma), Lancet, 1899, vol. i.— Hale White. Allbutt's
System of Medicine, vol. iv. p. 194. — Williams, R. (Malignant Disease in Early Life), Lancet,
1897, vol. i. p. 1328.

Ictekus Gravis

Icterus Gravis —
Nature
Relation to Acute Atrophy

Acute Yellow Atrophy —
Incidence
Etiology

554
555

555
555

Relation to Phosphorus Poison-
ing .
Morbid Anatomy
Symptoms and Signs
Diagnosis
Prognosis
Treatment

556
557
559
560
560
560

Nature. — Icterus gravis, or malignant jaundice, is a term somewhat
loosely used for cases where there is extensive degeneration of the liver-cells
combined with toxsemic jaundice, and a tendency to a fatal termination. It
thus includes a number of different conditions, such as the most severe
cases of febrile jaundice or Weil's disease, acute yellow atrophy of the liver,
phosphorus and other forms of mineral poisoning, and other cases where an

LIVER, DISEASES OF 555

acute toxacmic or infective condition of the body falls on the liver and gives
rise to widespread acute degenerative and necrotic changes in the liver-
cells ; for example, in yellow fever and in streptococcal and staphylococcal
hgemic infections. The term icterus gravis may also appropriately be applied
to cases where acute degenerative changes are superimposed on some pre-
existing disease of the liver, such as cirrhosis or nutmeg liver.

Icterus gravis should therefore be regarded, not as a specific disease, but
as a group of symptoms due to the rapid development of hepatic
insufficiency, eventually becoming absolute, which may be due to many
different causes.

Icterus gravis may be divided into —

(a) Those cases where the liver was previously healthy, e.g. in phosphorus
poisoning, acute yellow atrophy, or yellow fever.

(b) Those cases where it supervenes as a terminal lesion on pre-existing
hepatic disease, e.g. in cirrhosis or chronic venous engorgement.

Relation to Acute Atrophy. — Acute yellow atrophy is a special form of
icterus gravis, and may be regarded as a typical variety, since it is uncom-
plicated by the presence of any other disease. The terms icterus gravis and
acute yellow atrophy are not absolutely synonymous, for all cases of icterus
gravis do not show the naked-eye appearances of acute yellow atrophy of
the liver, though the essential change — acute degenerative changes in the
liver-cells — is much the same in both. Under the microscope the appear-
ances are so closely allied that from a pathological point of view they may
be said to pass into each other.

Generally speaking, the liver is somewhat enlarged in icterus gravis, and
the degenerative changes are not so markedly necrotic . as in acute yellow
atrophy.

Since some of the various conditions, such as acute yellow atrophy,
phosphorus poisoning, and Weil's disease, that are or may be included under
the generic term icterus gravis, will be separately described, the clinical
features of icterus gravis do not require any further description than that
found under the heading of acute yellow atrophy.

Acute Yellow Atkophy

Acute Atrophy of the Liver. — Definition. — An acute degeneration of
the liver-cells with diminution in size of the liver, jaundice, haemorrhages,
nervous symptoms, and usually a fatal termination.

Incidence. — That this is a rare disease is shown by the fact that Osier
has never seen a case ; curiously enough some observers have met with a
number of cases in a short time, Reiss saw 5 cases in 3 months. In a per-
sonal experience of 11 years I have met with 6 cases with autopsies. Up
to 1894 W. Hunter was only able to refer to 250 published cases, and in
the succeeding 4 years M'Phedran collected 29 more. In 25 years 7 cases
occurred at St. Bartholomew's Hospital, which according to Brunton and
Tunnicliffe is 1 in every 500,000 applications for treatment at that charity.
In 27 years there were 11 cases brought to autopsy at Guy's (Hilton
Fagge).

Etiology. — Age and Sex. — It is commonest between the ages of 20 and 30.
According to Hunter's figures half the cases occur in this decade, and four-
fifths between the ages of 10 and 40. A certain proportion — I have col-
lected 21 such cases — occur within the first 10 years of life ; exceptionally
it has been seen within the first year or even shortly after birth.

Females are more often attacked than males, the proportion between

556 LIVER, DISEASES OF

the two being nearly 2 to 1. Wilks puts the proportion higher — two-thirds
in women. This greater incidence of the disease in women seems to depend
on a special association between pregnancy and this disease.

Pregnancy. — The influence of pregnancy is borne out by the fact that
a large proportion of the cases occur in connection with this event. The
liver is, it appears, peculiarly susceptible to morbid changes during preg-
nancy, and there is reason to believe that degenerative changes in the
liver play a very important part in the production of puerperal eclampsia.
As to the period of pregnancy at which acute yellow atrophy occurs,
statistics show that it is commonest from the fourth to the seventh month.

Mental disturbance, shock, or fright has preceded the onset of the disease
in a certain number of cases. The mental worry in persons with syphilis
or in women that are pregnant, especially if unmarried, may tend further
to depress the resistance of the body and so dispose to the disease.

In six fatal cases recorded by Hardie of acute yellow atrophy of the
liver in Australia, importance was attached to the anxiety and fear with
which women look forward to parturition in hot climates.

Syphilis. — The secondary stage of syphilis is sometimes accompanied by
jaundice ; this is usually harmless and yields to specific treatment. In rare
instances acute yellow atrophy supervenes. This is said to be more often
seen in women than in men. The syphilitic toxin would appear to attack
the liver acutely just as it sometimes attacks the spinal cord, giving rise to
acute myelitis.

Alcoholic excess in a few instances has apparently stood in a causal rela-
tion to acute yellow atrophy ; in some instances the condition of acute red
atrophy has been found after recent and undoubted excessive indulgence.

Inasmuch as alcohol is a protoplasmic poison, it is not improbable that
the resistance of the liver being diminished by alcoholic excess, other causes
making for acute yellow atrophy are thus enabled to become effective.

The Influence of pre-existing Hepatic Disease. — The lesions of acute yellow
atrophy may supervene in the course of morbid conditions of the liver such
as cirrhosis, chronic venous congestion, or gall-stone obstruction. The onset
is no doubt disposed to by the morbid condition of the organ. In these
cases it is more convenient to describe the condition as icterus gravis rather
than as acute yellow atrophy.

Relation to Phosphorus Poisoning. — Inasmuch as there is considerable
resemblance between the clinical features of acute yellow atrophy and
phosphorus poisoning, it has been thought that all cases of acute yellow
atrophy are due to phosphorus poisoning. In support of this it might be
urged that examples of what were for a time considered undoubted ex-
amples of acute yellow atrophy have on further inquiry turned out to be
due to phosphorus poisoning.

Generally speaking, however, the differences between the two conditions
are sufficiently marked to separate them and not to warrant the assumption
that they are the same.

The differences are : —

(i.) In acute yellow atrophy the diminution in size is practically constant,
whereas in phosphorus poisoning enlargement is the rule.

(ii.) In acute yellow atrophy the changes in the liver-cells lead to rapid
disintegration with but slight increase in the amount of fat ; while in
phosphorus poisoning there is very extensive fatty change in the liver-
cells, the amount of fat in the organ reaching 30 per cent as against 5 per
cent in acute yellow atrophy.

It may be safely assumed that the two conditions are allied forms of

LIVEB, DISEASES OF 557

icterus gravis, but there is no proof of the view that they are one and the
same.

Morbid Anatomy. — The liver is greatly diminished in size and in weight ;
it may be half or even a third of its normal weight, often scaling 28 oz.
instead of the normal 50 oz. It is uniformly atrophied in most cases, but
exceptionally the less affected parts may form rather prominent projections.
The changes are often more marked on the left lobe, where the morbid
process probably often begins.

The capsule is wrinkled and loose, so that it can be picked up by the
fingers, like the walls of a half-filled bladder. If a stream of water is
turned on to the surface of the liver the capsule is thrown into folds and
wrinkles by the jet of water. The outside of the organ has a greenish
yellow colour with red splashes ; subserous haemorrhages may be present
under the capsule.

The liver is flabby and limp, and collapses and bends under its own
weight ; thus it readily doubles over on itself and is without the rigidity of
a normal liver. This flabbiness of the organ allows it to drop back during
life from the abdominal wall, its place being taken by the colon. As a
result the liver dulness may be entirely absent.

The liver cuts with the same kind of resistance that collapsed lung does,
and though very flabby is not softer or more easily broken down by the
finger than in health. Many writers, however, state that the liver is
softened. Possibly this is more true in icterus gravis.

On section of the organ the surface is seen to be of a bright yellow
colour. Usually, in addition to the more general yellow atrophy there are
areas of red atrophy. As a rule there is more of the yellow change, but in
some rare examples of what have been called acute red atrophy, diffuse red
atrophy greatly predominates or is universal. In the red areas the degener-
ative change is of oldest duration, while in the yellow areas it is more
recent. It would appear that the longer the patient lives the greater will
be the extent of the red change found after death. Acute red atrophy is
thus a further stage of acute yellow atrophy, and not a distinct condition.
According to Hilton Fagge the red atrophy is often more extensive in the
left lobe.

The outlines of the lobules are lost in the red areas, and with difficulty,
if at all, discernible in the yellow areas ; if visible, they are much smaller
than in health.

The gall-bladder contains bile, but the larger bile ducts often only show
mucus.

A scraping of the fresh section shows, under the microscope, blood
corpuscles, degenerated liver -cells, and crystals of leucin, tyrosin, and
xanthin. Leucin and tyrosin may be found in the blood of the veins of
the liver, in the kidneys, and in the spirit in which portions of the liver
have been preserved. In the alcoholic extract of the liver of acute yellow
atrophy that had been kept for two years Dele'pine found Charcot-Leyden
crystals.

Histologically the appearances vary with the intensity of the change ;
for, as pointed out, the liver may suffer unequally in different parts. The
liver-cells are disorganised, shrunken, angular, and yellow from bile ; they
stain badly, the nuclei being obscured. The protoplasm of the cells is
granular and often contains pigment. It may indeed be difficult to recognise
the tissue as liver except for the remains of the portal spaces, the appear-
ances being chiefly those of cell debris, small-cell infiltration, and nuclei.
There is small -cell infiltration in the portal spaces, starting from the

558 LIVEE, DISEASES OF

portal vein and spreading into the lobules between the columns of liver-
cells. Small -cell infiltration may also be seen around the intralobular
veins. In chronic cases, or where the acute change supervenes on cirrhosis,
considerable fibrosis may be present.

There is an increase in the amount of fat that can be extracted from
the liver, some 5 per cent, but this by no means compares with the very con-
siderable amount found in the liver of phosphorus poisoning.

In fresh sections crystals of leucin and tyrosin are seen. In places
blood corpuscles are seen extravasated among the disorganised liver-cells.
The smaller bile ducts show signs of proliferation, cholangitis, thus ex-
plaining the jaundice.

The appearances known as pseudo-bile canaliculi, consisting of columns
of small cubical cells, are prominent in the small portal spaces, and may be
regarded as an attempt at compensatory hyperplasia on the part of the
remaining, comparatively healthy, liver-cells. The liver-cells divide, and
thus small cells resembling minute bile duct's are produced. These regener-
ative processes are better marked when the disease is prolonged, and may
not have time to develop when its course is very rapid. This regenerative
process in acute yellow atrophy has been specially studied by Meder,
Marchand, and Stroebe. In parts where the changes are less marked the
liver-cells may be seen forming columns of larger size than the pseudo-bile
canaliculi, as if the organ was reverting to the embryonic type of liver.

Micro-organisms have been found in some cases, but not in others, and
no definite causal connection can be said to exist between any micro-
organism and the changes found. Probably several different kinds of
micro-organisms, as well as several poisons, are capable of producing the
acute inflammatory and degenerative changes characterising acute yellow
atrophy of the liver.

The kidneys are swollen, soft, bile-stained, and show small haemorrhages.
Microscopically the epithelium of the tubules shows degeneration.

The spleen is softened, as in infective diseases, and often enlarged.

The heart is softened and swollen, and shows cloudy swelling. The
blood, as in other toxic and septic conditions, stains the walls of the vessels
and coagulates imperfectly. Hemorrhages are found scattered through
the body on the cutaneous, mucous, and serous surfaces. Meningeal and
cerebral (Lafitte) haemorrhages have been known to occur. Toxic changes
in the vessel walls allow extravasation to take place. Brunton and Tunni-
cliffe point out that viperine poison has the same effect when applied
locally to the mesentery of a frog.

The intestinal tract shows catarrhal inflammation and degeneration,
while patches of necrosis in the stomach have been met with.

The body thus shows widespread degeneration due to a virulent poison.
Changes of this nature have been described in the spinal cord.

Nature of the Change. — The essential factor is a very acute necrotic
degeneration of the liver -cells with evidences of inflammation in the
supporting fibrous tissue of the organ. The condition is a very acute
hepatitis ; chronic or protracted cases have been regarded as acute cirrhosis.
It is analogous to, but more acute than the toxic changes seen in the liver,-in
phosphorus, iodoform, arsenic poisoning, or in lupinosis. In Germany many
sheep die with jaundice, hsemorrhages, delirium, and acute yellow atrophy
of the liver as a result of eating certain lupins. This disease — lupinosis
— which is not met with in man, is thought to be due to a poison — ictrogen
or lupinotoxin — produced by the agency of fungi in the husks of the seeds.

Where the poisons that lead to acute yellow atrophy are primarily

LIVEE, DISEASES OF 559

produced is nob known. But whether produced in the liver or elsewhere,
the body suffers as a whole. In some instances the change in the liver
may be a local manifestation of a general infection or intoxication, while
in other instances the liver may be primarily involved and the body
secondarily affected.

Symptoms. — At the onset there may be nothing to distinguish the
disease from ordinary catarrhal jaundice. It is true there is generally
some rise of temperature, but this is often seen in the innocent jaundice,
and is not enough to justify a gloomy prognosis. There is malaise,
vomiting, constipation, bilious urine, and not uncommonly muscular pains.

This stage usually lasts five or six days, but may be prolonged for several
weeks ; it is succeeded by signs of mental disturbance, headache, delirium,
screaming, restlessness, coma, and occasionally convulsions. The jaundice
becomes more marked. It is due to obstruction in the smaller bile ducts,
the result of inflammatory lesions in their walls produced by the same
poison that is responsible for the acute degenerative changes in the liver-
cells. In some exceptional cases of acute yellow atrophy there is no jaundice.
With the onset of these grave symptoms vomiting becomes urgent.
The tongue is usually dry, brown, and tremulous, and the teeth become
coated with sordes. Dilatation of the pupils has been regarded as an
important sign, and has been so extreme as to suggest belladonna poisoning ;
with the onset of grave symptoms the pulse quickens and becomes feeble
and of low tension. The respiratory rate tends to be quickened or to
become irregular.

The temperature varies, but is more often depressed than raised ; it has
been observed to rise before death. The presence or absence of fever has
theoretically been correlated by Hanot with different microbic poisons,
infection with the colon bacillus leading, like phosphorus poisoning, to a
depressed temperature, while streptococcal and staphylococcal infections
lead to pyrexia. Occasionally a red rash appears on the skin. Petechias
and haemorrhages occur under the skin, and blood may be passed in the
motions ; occasionally epistaxis and hsematuria are observed, and in women
metrorrhagia. Pregnant women abort.

The fseces may be darkened by blood so as to resemble bile ; in the
later stage it is improbable that bile passes into the duodenum, inasmuch
as the bile ducts contain nothing but mucus. But as constipation exists
throughout the disease, some of the faeces may contain bile excreted into
the bowel at a very early stage of the disease. The dejecta are often
extremely offensive. Diarrhoea is exceptional.

Urine. — The amount is somewhat diminished ; it is high-coloured from
bile pigment, and possibly in some instances from excess of urobilin. Albu-
min and tube casts may be present. The amount of urea is greatly
diminished.

Leucin and tyrosin, to which great importance is attached as replacing
the urea and signifying the functional failure of the liver, are not
invariably present, hence their absence does not disprove the existence of
acute yellow atrophy. Sometimes one is present without the other. Leucin
and tyrosin are sometimes spontaneously deposited from the urine.

On the other hand, leucin and tyrosin may be present in the urine in
diseases where the liver is not affected in any way comparable to acute
yellow atrophy, for example in erysipelas, typhoid fever, leukaemia, variola.
Liver Dulness. — At the onset of grave symptoms the liver may or may
not be found to be enlarged ; this may be due to pre-existing disease such
as cirrhosis, but it has been noticed in cases where this explanation does

560 LIVEE, DISEASES OE

not hold. This enlargement is succeeded by diminution of the liver dulness,
which may proceed rapidly until it entirely disappears. The complete
disappearance is due to the atrophied and flabby liver falling away from the
abdominal wall and allowing the colon to take its place.

The liver is tender on pressure.

The spleen may be made out to be enlarged.

Some degree of ascites may be present.

The stage of severe symptoms usually lasts for two days, and is followed
by death in coma. In some' instances the stage is prolonged; acute,
subacute, and protracted classes have been made to embrace cases of vary-
ing severity. The protracted cases show changes which perhaps justify the
term acute cirrhosis.

Diagnosis. — From phosphorus and allied forms of poisoning; the
absence of any evidence that phosphorus or other poison has been taken
or vomited is of course all-important. The progressive diminution in the
hepatic dulness and the diminution in the amount of urea in the urine
are strongly in favour of acute yellow atrophy. The presence of leucin
and tyrosin is not conclusive, as they may be absent on the one hand in
acute atrophy, and on the other hand be present in phosphorus poisoning,,
and in other conditions, such as typhoid fever, erysipelas, and even occa-
sionally in leuksemia.

In phosphorus poisoning there is an interval between the severe
symptoms due to its irritant action and the onset of jaundice with severe
constitutional symptoms ; there is no interval between the first and second
stages of acute yellow atrophy. There is more gastric irritation in phos-
phorus poisoning.

In biliary cirrhosis the progress of the disease is very chronic, while the
liver is enlarged.

Prognosis. — When the disease has fully declared itself the prognosis is
most gloomy ; in fact, doubt must always arise as to the nature of cases
that recover, and where an opportunity for examining the liver is not
provided by death later. Some of the cases, of which a good number are
on record, may have been examples of infective jaundice or Weil's disease
of a severe character.

I have had such a case under my own care where the diagnosis of acute atrophy,
and death, the patient being in a condition of coma, seemed equally certain, but
where recovery followed. Fagge refers to a case where a subsequent post-mortem
showed the changes of acute yellow atrophy in a patient who recovered from
the acute symptoms.

V. Kahlden reports a case in which death occurred some months after the
acute symptoms, and where cirrhosis was in process of development as a result of
the changes. This case is open to the explanation that it was one of acute
hepatitis and icterus gravis rather than one of acute yellow atrophy.

Although doubt may arise as to the real nature of the lesion in the cases
that recover after manifesting the characteristic symptoms, there are ample
grounds for the statement that this does occur.

Treatment. — There is no means known of curing the disease ; theoretic-
ally free purgation in the early stages of the disease, to eliminate the
toxins before their degenerative effects have been produced, might be
recommended. Intestinal antiseptics, such as salol and /3-naphthol, to
reduce auto-intoxication as far as possible, may be given.

The excretion of the kidneys should be increased by the administration
of citrate of caffein and free draughts of water. Intravenous transfusion
has been performed with transient improvement.

Milk diet only should be given.

History

. 561

Symptoms

Nature

. 561

Diagnosis

Etiology

. 561

Prognosis

Bacteriology

. 561

Treatment

Morbid Anatomy

. 561

LIVEE, DISEASES OF 561

Vomiting may be combated by bismuth, dilute hydrocyanic acid,
bimeconate of morphia, and effervescing mixtures.

LITERATURE. — Brunton and Tunnicliffe. St. Bartholomew's Hospital Reports, vol.
xxxii. p. 425 (Lupinosis). — Delepine. Trans. Path. Soc. vol. xlii. p. 458. — Fagge, Hilton.
Principles and Practice of Medicine, edited by Pye Smith, 3rd ed. vol. ii. p. 377. — Gold-
schiedeh and Moxter. Fortschritte der Med. 1897, No. 14 (Spinal Cord). — Hanot. Le
Bull. mid. 1893. — Hunter. Allbutt's System, vol. iv. — v. Kahlden. Munch, mcd. Wochen.
Oct. 5, 1897. — Lafitte. Bull. soc. anat. Par. 1891. — Legg, J. Wickham. On the Bile,
Jaundice, and Bilious Diseases, 1880, p. 412. — Marchand. Ziegler's Beitrage, Bd. xvi. S. 20(3.
— Meder. Ziegler's Beitrage, Bd. xvi. S. 143. — M'Phedran. Sajous' Annual, 1899, vol. iv.
]). 393. — Stroebe. Ziegler's Beitrage, Bd. xvii. S. 379. — Wilks. Pathological Anatomy, p.
447, 3rd ed. 1889.

Weil's Disease

. 562
. 562
. 562
. 562

Synonyms. — Infective Jaundice ; Bilious Typhoid.

History. — In 1886 Weil described a condition of febrile jaundice associ-
ated with nephritis and enlargement of the spleen. It occurs in epidemics,
one of which had previously been described by Weiss in 1866 as infectious
jaundice. The disease was called after Weil of Heidelberg by his compatriots,
but the French school did not consider it was different from icterus gravis or
infectious jaundice. This unwillingness to acknowledge it as a new disease
distinct from other forms of infectious jaundice is shared by Hunter in his
article in Allbutt's System of Medicine.

Nature. — Weil's disease is an excellent example of acute infective
jaundice secondary to a hsemic infection, the nature of which has not been
satisfactorily established. The jaundice is toxsemic, and has close analogies
with that induced experimentally by means of toluylenediamine. It is
allied to, but less acute than acute yellow atrophy of the liver, and cases
formerly recorded as examples of recovery from acute yellow atrophy would
probably be regarded now by many as Weil's disease.

Etiology. — It usually occurs in males between the ages of 20 and 40,
but children are sometimes affected. It is more likely to attack sewermen,
butchers, soldiers, and others who follow certain occupations that expose
the workers to infection. The onset of the disease is sometimes attributed
to poisoning by bad meat.

Most of the cases occur in the summer months, and are met with in
epidemics. It may arise repeatedly in the same place.

Bacteriology. — Jaeger and Banti have described a proteus bacillus in
the blood. The former observer found the same organism in ducks dying
of jaundice that frequented the water where his patients had bathed and
presumably had been infected ; the bacillus he described as B. proteus
fluorescens.

Further observations are required on this point.

Morbid Anatomy. — The tissues of the body show the effects of a
general toxic process. There is cloudy swelling of the cells of the kidney,
liver, and heart muscle, going on to the further change of fatty metamor-
phosis. The changes in the liver may progress further and resemble those
in acute yellow atrophy ; the mucous membrane of the bile ducts becomes
swollen and degenerated.

Haemorrhages may be present in the skin, mucous and serous membranes.
vol. vi 36

562 LIVER, DISEASES OF

The spleen is swollen.

Symptoms. — The disease begins with malaise, headache, fever, pains in
the limbs, and generally speaking resembles influenza at its commencement.
The pulse is rapid (120), but becomes slower after the onset of jaundice.

Jaundice begins on the second or third day, is generally slight, and lasts
about two weeks ; the motions may be clay-coloured, but usually contain
bile, and are often loose.

The liver becomes enlarged and tender, and a marked feature of the
disease is the splenic enlargement.

Fever reaching 103°- 104° Fahr. lasts for about a week; the temperature
then falls and becomes normal at about the tenth day.

The urine is albuminous, contains bile pigment, and sometimes blood
and bile acids. The presence of casts shows that there is tubal nephritis.

The pains in the limbs are especially marked in the calves ; there is
great prostration, giddiness, and some delirium at night.

Epistaxis, purpura, and various cutaneous rashes such as herpes, ery-
thema, and urticaria may be met with.

A relapse may occur a week or so after the temperature has become
normal ; its occurrence may be suspected if after the end of the first attack
the spleen remains enlarged. The relapse lasts about a week. Chauffart
describes Weil's disease as " relapsing infectious jaundice," but in Germany
relapses are comparatively infrequently described ; thus in 84 cases, of
which 73 were collected from German literature, Tymowski found that
relapses were mentioned in 19.

Diagnosis. — From epidemic catarrhal jaundice it is distinguished by
its greater severity and evidence of its being not a local disease limited to
the bile ducts, but a general infection, as shown by albuminuria and hemor-
rhages, with secondary implication of the liver. The association with
albuminuria would at once differentiate it from simple or from epidemic
jaundice, or from the epidemic form that is sometimes seen in association
with influenza.

From enteric fever the Widal's reaction would distinguish it. It was
formerly described as " bilious typhoid " by Griesinger, but the lesions of
typhoid fever are not found in the body after death, and further it is
extremely rare to see jaundice associated with typhoid fever.

The more severe examples of Weil's disease approach icterus gravis and
acute yellow atrophy ; the difference is one of degree, as far as our present
knowledge goes.

Eelapsing fever should be recognised by examination of the blood and
the presence of the spirillum Obermeieri.

Hsemoglobinuric fever should be recognised by examination of the
blood, by the history of exposure to malaria, and by the vomiting.

The Prognosis is fairly favourable, but convalescence may be protracted.

Tkeatment. — The patient should remain in bed until after the tempera-
ture has become normal, and should be restricted to a milk diet. All
alcoholic drinks should be interdicted, and the patient should be encouraged
to drink freely of water.

Intestinal antiseptics, such as salol, salicylate of bismuth, or /5-naphthol,

should be given.

LITERATURE. — Chauffart. TraitS de mddecine, Charcot, Bouchard, tome iii. p. 754.
— Hunter. Allbutt's System, vol. iv. p. 95. — Mathieu. Gaz. des hdp. 1891, Jan. 27. —
Tymowski, quoted by Chauffart.

Printed by R. & R. Clark, Limited, Edinburgh.

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